(navigation image)
Home American Libraries | Canadian Libraries | Universal Library | Community Texts | Project Gutenberg | Children's Library | Biodiversity Heritage Library | Additional Collections
Search: Advanced Search
Anonymous User (login or join us)
Upload
See other formats

Full text of "United States Navy Medical News Letter Vol. 45 No. 4, 26 February 1965"

NAVMED P-5088 



fc TJNITED STATES NATV^T 

f Medical News Letter 



Vol. 45 



Friday, 26 February 1965 



No. 4 




CONTENTS 



MEDICAL ABSTRACTS 

Malpractice and The Service Doctor 1 

What Kind of Leadership Approach? 5 



FROM THE NOTE BOOK 

Availability of Neuropsychiatric Residencies in Naval 

Hospitals 7 

ACOG Annual Clinical Meeting 8 

American Board of Ob-Gyn 8 

Ophthalmic Pathology Course 8 

American College of Physicians Annual Meeting 8 

Naval Medical Research Reports 8 

DENTAL SECTION 

Palpal Reactions to Caries 9 

Effectiveness of Copal Resin Varnish Under Amalgam 

Restorations 9 

Effect of Powered Toothbrushing Plus Inter-Dental 

Stimulation Upon Severity of Gingivitis 10 

Extradietary Fluoride Supplementation 10 



DENTAL SECTION (Cont'd) 

Dental X-Ray Exposure of Sites Within the Head 

and Neck 

Personnel and Professional Notes 

AVIATION MEDICINE 



11 

12 



14 

19 



20 



Medical Aspects of Operation Sea Orbit, First Round- 
the-World Cruise by Nuclear Powered Surface 
Ships 

After that "Hairy One" 

MISCELLANY 

Nursing Seminar on the Acute Coronary Patient 

Four U.S. Navy Nurse Corps Officers Receive Purple 

Heart Awards in Vietnam 21 

Report on New U.S. Naval Dental Training Film 21 

Addendum to Article on USNH, Philadelphia, De- 
scribing the U.S. Naval Aural Rehabilitation Center 21 

SPECIAL ARTICLES 

Cat Scratch Disease 22 

Pediatric Office Bacteriology 22 



United States Navy 
MEDICAL NEWS LETTER 



Vol. 45 



Friday, 26 February 1965 



Rear Admiral Robert B. Brown MC USN 

Surgeon General 

Captain M. W, Arnold MC USN (Ret), Editor 
William A. Kline, Managing Editor 

Contributing Editors 

Aviation Medicine Captain C. E. Wilbur MC USN 

Dental Section Captain C. A, Ostrom DC USN 

Occupational Medicine CDR N. E. Rosenwinkel MC USN 

Preventive Medicine Captain J. W. Millar MC USN 

Radiation Medicine CDR J. H. Schulte MC USN 

Reserve Section Captain C. Cummings MC USNR 

Submarine Medicine CDR J. H. Schulte MC USN 



No. 4 



Policy 
The U.S. Navy Medical News Letter is basically an 
official Medical Department publication inviting the 
attention of officers of the Medical Department of the 
Regular Navy and Naval Reserve to timely up-to-date 
items of official and professional interest relative to 
medicine, dentistry, and allied sciences. The amount 
of information used is only that necessary to inform 
adequately officers of the Medical Department of the 
existence and source of such information. The items 
used are neither intended to be, nor are they, sus- 



ceptible to use by any officer as a substitute for any 
item or article in its original form. All readers of the 
News Letter are urged to obtain the original of those 
items of particular interest to the individual. 

Change of Address 

Please forward changes of address for the News Letter 
to: Commanding Officer, U.S. Naval Medical School, 
National Naval Medical Center, Bethesda, Maryland 
20014, giving full name, rank, corps, and old and new 
addresses. 



FRONT COVER: Aerial view of the U.S. Naval Hospital, Camp Lejeune, N.C. Commissioned on 1 May 1943 
at a construction cost of $7,500,000, this hospital is a self-contained command under management and technical 
control of the Bureau of Medicine and Surgery, Navy Department. Coordination control is exercised by the 
Commandant, Fifth Naval District and military control by the Commanding General, Marine Corps Base, Camp 
Lejeune, N.C. The mission is hospitalization support for military personnel and dependents of the Marine Corps 
Base; Force Troops, Second Marine Division; Marine Corps Air Facility, New River; and Marine Corps Air 
Station, Cherry Point, N.C. 

Authorized operating bed capacity is 475, with an expanded capacity of 1,173 beds. The peak patient load 
during WW II was 2087^during Korean Conflict, 1,865. Since commissioning, the hospital has admitted approx- 
imately 87,000 military patients and 77,500 others. There has been a total of 45,000 births recorded. Fully 
accredited by the Joint Commission on Accreditation of Hospitals, specialist clinical services now include General 
Medicine, General Surgery, Orthopaedic Surgery, Obstetrics and Gynecology, Pediatrics, Ophthalmology, Urology, 
Radiology, Pathology, Otorhinolaryngology, Neuropsychiatry, Dentistry, Pharmacy and Physiotherapy.— (From 
the hospital's 20th Anniversary Brochure, May 1963. Commanding Officer: Capt. Frank T. Norris, MC, USN.) 

The issuance of this publication approved by the Secretary of the Navy on 4 May 1964. 

U.S. NAVY MEDICAL NEWS LETTER 



MALPRACTICE AND THE SERVICE DOCTOR 



LCOL Raymond Coward JAGC USA.'" 
United States Armed Forces Medical Journal IX(2): 232-240, February 1958. 



OVERSEAS AREAS 

The FTCA has no application with respect to claims 
arising in a foreign country and could not be the basis 
for a claim against a service doctor or the United States 
as a result of medical treatment the doctor rendered 
abroad. Also, the United States has not waived its sov- 
ereign immunity that prevents it from being sued in 
foreign courts. The Foreign Claims Act of 1942 3= per- 
mits claims against the United States by an inhabitant 
of the country in which the claim arose, and this Act 
has been implemented by Army Regulations, 32 but pro- 
cedures for handling claims by inhabitants of foreign 
countries would, for the most part, be inapplicable to 
the problems under discussion, as we are primarily con- 
sidering claims on the part of military personnel, civil- 
ian employees, or their dependents. 

Treaty arrangements between the United States and 
a foreign country also have a bearing on a claim arising 
in any particular country. In general such arrangements 
follow the pattern as set forth in Article VIII, NATO 
Status of Forces Agreement." Other similar treaty pro- 
visions are contained in the Japanese Administrative 
Agreement' 5 and the Bonn Conventions with Germany.'" 
Under such treaty provisions, claims arising out of the 
performance of official duties are processed and adjudi- 
cated by the foreign or receiving state according to its 
laws and procedures. Only when the claim arises out 
of a nonofficial act would it be processed under the 
previously named Federal statutes and regulations. In 
each of the treaties there is a provision that precludes 
recovery from the individual wrongdoer in a foreign 
court if his act was in the performance of official duties. 
The degree of protection an individual has from suit in 
a local foreign court depends upon the agreement, or 
lack of agreement, between the United States and the 
country concerned. 

Thus, it appears that as a result of treaty arrange- 
ments, and a reluctance on the part of United States 
citizens to litigate in foreign courts, there is little likeli- 
hood that a service doctor will be sued in a foreign 
court. 



* Colonel Coward 
Arkansas. 



now retired from the Army and lives at Searcy, 



EMERGENCIES 

The Federal Civil Defense Act," which became effec- 
tive on 12 January 1951, in effect suspends the cover- 
age afforded under the provisions of the Federal Tort 
Claims Act in the event of a national emergency, as will 
be seen from section 2294 thereof which provides: 

The Federal Government shall not be liable for any 
damage to property or for any death or personal injury 
occurring directly or indirectly as a result of the exer- 
cise or performance of, or failure to exercise or per- 
form, any function or duty, by any Federal agency or 
employee of the Government, in carrying out the pro- 
visions of this title during the period of such emergency. 
Nothing contained in this section shall affect the right 
of any person to receive any benefit or compensation to 
which he might otherwise be entitled under the Federal 
Employees' Compensation Act, as amended. 

It will be seen that this statute excuses the Govern- 
ment from liability for damages or injuries occurring 
as a result of the performance of, or failure to perform, 
any function or duty by any Federal agency or em- 
ployee of the Government in carrying out its provisions 
in an emergency, and the United States has not waived 
its immunity from suit under such circumstances. 

MALPRACTICE INSURANCE 

There are relatively few insurance companies that 
will write malpractice or medical professional liability 
insurance and the rate is substantially higher for a 
doctor who desires surgical, x-ray, or shock treatment 
coverage than for the general practitioner. These dis- 
tinctions apply equally to military doctors, but rates are 
generally lower for them than for civilian doctors. 
Presumably the main reason for this is the knowledge 
that Government lawyers will defend suits brought 
under the Federal Tort Claims Act. 

The policy followed by The Surgeon General as to 
whether an Army doctor or nurse should carry mal- 
practice insurance is that each one should decide this 
matter individually. The question arises occasionally 
whether the Department of the Army should pay mal- 



U.S. NAVY MEDICAL NEWS LETTER 



practice insurance premiums to protect Army doctors; 
however, there is no known authority in existing per- 
manent law or current appropriation acts that would 
permit the Army to pay such premiums out of funds 
appropriated by Congress. Further, if legislation should 
be proposed which would authorize the Army to pay 
malpractice insurance premiums, it appears likely that 
the Department of the Army would oppose its enact- 
ment. This is indicated by the position taken in 1955 
with respect to H.R. 10577, 84th Congress, a bill "To 
provide for the procurement by the Government jf in- 
surance against risk to civilian personnel of liability for 
personal injury or death, or for property damage, aris- 
ing from the operation of motor vehicles in the per- 
formance of official Government duties, and for other 
purposes." In opposing this bill the Department of the 
Army stated: 

The bill would provide a limited amount of liability 
insurance or alternatively virtually complete indemni- 
fication for a limited class of Federal employees subject 
only to the provision that in any such case the act of 
an employee forming the basis for such action must be 
found to be 'in the performance of his official duties.' 
It contains no standard of conduct for the officers and 
employees to be protected and no standard of responsi- 
bility for potential insurers. . . The Federal Tort Claims 
Act, supra, now provides ample protection to third 
parties damaged or injured by the actions or omissions 
of Government workers acting within the scope of their 
employment. 

The Department of the Army also stated that gov- 
ernment procurement of commercial insurance would 
be unusual. It added, "It long has been the settled 
policy of the United States to assume its own risks (35 
Comp. Gen. 391, 392)." 

PATIENT'S RIGHT TO PRIVACY 

There is a growing tendency to recognize the right of 
privacy as enforceable by an action in tort. 38 Under 
certain circumstances, tort action could be brought 
against a physician for violation of the patient's right 
to privacy, on the basis that "A person who unreason- 
ably and seriously interferes with another's interest in 
not having his affairs known or his likeness exhibited 
to the public is liable to the other." 3 " 

The information that the doctor learns about the 
patient in the course of examination and treatment is in 
the nature of privileged communication and should not 
be revealed to unauthorized individuals without the 
specific consent of the patient. When a patient disrobes 
for any type of medical procedure, he does so for the 
professional benefit of the doctor, and unless he gives 
consent there should not be admitted either medical or 
nonmedical personnel who are not essential to the 
carrying out of the particular medical procedure.™ To 
do otherwise is to violate the patient's right to privacy. 



Written consent should be obtained in order to take 
pictures of the patient, and the pictures should be taken 
in such manner that the later use of them will not re- 
veal his identity unless he has authorized in writing that 
it be revealed. The mere taking of pictures that are not 
authorized by the patient may constitute a cause of 
action against the doctor, even if they are never pub- 
lished. 4 " This is true even though the pictures are for 
a worthy purpose such as advancing medical science. 

AUTOPSIES 

The performance of an unnecessary and unauthorized 
autopsy may subject the service doctor to a suit for 
damages by the next of kin or legal representatives of 
the deceased. The doctor might also be prosecuted for 
the violation of a criminal statute. The performance of 
an autopsy on the remains of a person who dies while 
serving on active duty in the military service is author- 
ized under the conditions set forth in Army Regulations 
as follows: 

b. Autopsies. 

(1) Deceased military personnel. An autopsy will 
be performed on the remains of any person who dies 
in the military service while serving on active duty 
when the commander or the surgeon of an installa- 
tion or command deems such procedure necessary in 
order to determine the true cause of death, and to 
secure information for the completion of military 
records. 11 

The same regulation requires written consent from the 
next of kin before performing an autopsy on a retired 
person or civilian who dies in a medical treatment 
facility or on a military installation. It also provides 
that an opinion defining "next of kin" should be ob- 
tained from the local judge advocate for the jurisdiction 
in which the installation is located. With respect to the 
performance of an autopsy on a civilian, the consent of 
the husband or wife or next of kin of the deceased is a 
prerequisite to the performance of an autopsy, unless 
the autopsy is performed, in accordance with the law, 
by or at the direction of the coroner or other authorized 
person, 

The wrongful dissection of a dead body is regarded 
as a willful and intentional wrong against the person 
entitled to the possession and control of the body for 
burial, and a recovery may be had for the mental 
anguish resulting from such a mutilation. The unau- 
thorized dissection is an interference with a legal right; 
the right to have immediate possession of the body in its 
condition at the time of death, and control for burial. 
A petition or complaint that alleges the right to a body, 
a refusal to deliver up the body on demand, and the 
performance of an unauthorized and wrongful autopsy 
thereon while it is withheld, states a cause of action. 
Further statutes in a number of states makes it a crime 
to perform an unauthorized autopsy. 43 



U.S. NAVY MEDICAL NEWS LETTER 



TRENDS IN MALPRACTICE CASES 

In recent years the public has become more informed 
concerning medical professional liability, and this may 
result in more claims against physicians and surgeons. 
The nature of the practice and procedures involved in 
some specialties make the doctors practicing in such 
specialties more likely to be sued. Based on the amounts 
recovered in some recent cases, larger claims may be 
expected to be made in the future. 

The Law Department, American Medical Associa- 
tion,' 1 made an analysis of 605 medical professional 
liability decisions reported in the United States from 
1935 through 1955. The study included all published 
decisions regardless of the level of the court involved. 
Of the 605 cases, which involved 782 doctors, the great- 
est number had to do with surgical procedures. The 
next largest number concerned nonsurgical treatment 
and involved such incidents as breaking a hypodermic 
needle in giving an injection, prescribing an unofficial 
drug, or being negligent in removing a foreign body 
from the eye. Treatment of fractures and of burns 
also ranked high in the list of causes for claims. 

THE DOCTOR IN COURT 

There are numerous ways, some voluntary and others 
involuntary, in which a doctor may come before the 
Court in connection with his medical knowledge and 
practice. He may receive a subpoena to appear as 
witness for either party in a case about which he has 
personal knowledge, he may appear as an expert wit- 
ness at the request of one of the parties to the suit, 
he may be suing a patient or employer, or he himself 
may be sued. In the latter case, the suit may be for 
breach of contract, for malpractice in rendering medical 
care, for assault and battery, for false imprisonment 
(where undue restraint of a patient is used), or for 
loss or damage to the property of a patient. 

Questions the Court Considers 

There are certain basic questions the Court must 
consider in an effort to determine liability in any case 
of negligence or malpractice. Some of the more im- 
portant questions are: 

1. Was there a duty on the part of defendant? 

2. Was there an injury, with resulting damages, to 
the plaintiff? 

3. Was the injury due to negligent action? 

4. Did the injury result directly from the negligent 
action? 

5. Did the doctor commit the negligent action or 
did he negligently omit to do something? 

6. Does the doctrine of res ipsa loquitur apply under 
the particular circumstances? 

7. What would a reasonable, prudent doctor have 
done under similar circumstances? 



In seeking an answer to the last question the problem 
would arise as to what standards should be applied as 
to the reasonableness of the medical procedure used 
in the particular case. The practice of medicine re- 
quires the exercise of judgment based on knowledge. 
The question at issue in a negligence case is whether 
proper judgment was exercised. The doctor is required 
to meet the level of professional community practice, in 
his own specialty, and not the level or skill of training 
possessed by the isolated or unusual practitioner. 

The Doctor as a Witness 

Before a doctor appears as a witness in a case he 
should assure himself that he is thoroughly familiar 
with the medical history and all clinical records of the 
case in issue. In a case involving a specialty or expert 
knowledge, he should review and establish firmly in 
his mind the medical principles that are recognized and 
accepted in the medical profession. In complicated 
cases he should take to court with him published medi- 
cal authorities to be cited in his testimony in support of 
his position. He may anticipate that he will be rigorous- 
ly cross-examined by opposing counsel as to the testi- 
mony he gives on direct-examination. A lawyer is 
trained to advocate the cause he represents. He seeks 
to make the most of any weak points which may appear 
in the testimony of witnesses on the opposing side of the 
case. The doctor should understand this and be pre- 
pared to meet it when he goes into court, rather than 
to indicate by his manner that he feels a reflection is 
being made upon his professional integrity. 

It is important for the medical witness to take his 
time in responding to questions and to enunciate his 
answer clearly and distinctly. He should avoid long, 
complicated, technical answers to questions, and should 
speak in plain, understandable layman's language so 
that the judge and jury will better understand his testi- 
mony. The credibility of the witness, or the extent to 
which the Court and jury may believe his testimony, 
is very important in a law suit. It has a bearing when 
the Court instructs the jury on the evidence applicable 
to the case and the jury weighs the evidence by com- 
paring the testimony given on one side with that pre- 
sented by the opposing party. 

SAFEGUARDS AGAINST 
MALPRACTICE CLAIMS 

Although it is understandable that the trend in mal- 
practice claims may cause the doctor concern, he must 
have the courage to act in line with his convictions as 
to what is best for the patient, using advanced methods 
of diagnosis and treatment where indicated, even though 
they involve certain risks. In doing this, there are 
certain standards or safeguards that, if observed by 
the practicing physician or surgeon, may avoid or at 
least reduce the number of medical professional liability 
claims. 



U.S. NAVY MEDICAL NEWS LETTER 



The following are suggested ways in which the doctor 
may reduce the likelihood of suit without jeopardizing 
the welfare of his patient: 

1. Avoid careless remarks about the medical treat- 
ment the patierit may have received previously from 
another doctor. 

2. Keep thorough, accurate, and complete medical 
records. These should include case history as well as 
clinical records, 

3. Make thorough examinations of the patient, in- 
cluding all necessary laboratory tests, roentgenograms, 
et cetera, and record the results in the patient's medical 
record. 

4. Obtain the confidence of the patient, establish 
rapport with him, and in general, improve the doctor- 
patient relationship as well as the relationship with the 
patient's family. 

5. Do not experiment with unproven medicines, pro- 
cedures, or technics, but adhere to proven and ac- 
cepted medical principles and practices. 

6. Do not guarantee cures or fixed degrees of im- 
provement as a result of following certain prescribed 
medical treatments. 

7. Explain the risks in surgical or medical procedures 
proposed, so that the patient understands the situation. 

8. Obtain the written consent of the patient and the 
next of kin, in appropriate cases, keeping in mind that 
for the consent to be valid there must be a full explana- 
tion of the procedures and the risks involved. 

9. In dealing with a patient with a mental illness, 
obtain the written consent of the next of kin if at all 
practicable, even though written consent of the patient 
is granted, as the patient's mental capacity to give valid 
consent may be put in issue at a later date. The ad- 
visability of having such a patient examined by more 
than one doctor also should be considered. This will 
afford the doctor better protection, particularly in a 
case where restraint is used, as he may later be charged 
with false imprisonment. 

10. Beware of the dangers involved in diagnosis and 
prescription by telephone, without seeing or examining 
the patient. 

SUMMARY 

Malpractice or medica! professional liability claims 
are recognized throughout the United States. The doctor 
in government service is less likely to be sued in his 
individual capacity than a doctor in private practice, 
because of the protection afforded him by the Federal 
Tort Claims Act and other Federal laws and regulations. 
If the service doctor is sued in a state court for acts 
performed in a service hospital within the scope of his 
employment or in connection with his official duties, 
he may have the case removed to a Federal court for 



trial. Under procedures outlined in published Army 
Regulations, the Army doctor may also make arrange- 
ments for the United States Attorney to defend him 
along with the Government. As a result, the rates for 
medical professional liability insurance are considerably 
lower for doctors in the Federal service than for those 
in private practice. The Surgeon General, Department 
of the Army, follows the policy of leaving it to each 
Army doctor to decide as to whether he should carry 
insurance. There is no current authority for payment 
of insurance premiums out of funds appropriated by 
Congress, and it is the policy of the United States to 
assume its own risks. 

The patient's welfare should not be jeopardized 
through a reluctance on the part of the doctor to 
prescribe and render necessary medical treatment in an 
effort to protect himself from a possible malpractice 
claim, but there are safeguards that, if followed, will 
greatly reduce the likelihood of malpractice claims. 

REFERENCES 



9. 
10. 
11. 
12. 
13. 
14. 
15. 
16. 
17. 
IS. 
19. 
20. 
21. 
22. 
23. 
24, 
25. 
26. 
27. 
28. 

29. 
30 
31. 
32. 
33. 
34. 
35. 
36. 

37, 
38. 

39. 
40. 

41. 
42. 



Black's Law Dictionary. 4th Edition, p. 1111, citing Gregory v. 

Mclnnis, 140 S.C. 52; 134 S.E. 527, 529. 

Rodgers v. Kline, 56 Miss. 816, 31 Am. Rep. 389; Hibbard v. 

Thompson, 109 Mass. 288; Napier v. Greenzweig, C.C.A.N.Y., 

256 F. 196, 197. 

Black's Law Dictionary. 4th Edition, p. 1184, citing Schneeweisz 

v. Illinois Central R. Co., 196 111. App. 248, 253, et al. 

Black's Law Dictionary. 4th edition, p. 1660, citing Coleman v. 

California Yearly Meeting of Friend's Church, 27 Cal.App.2d 579, 

81 P. 2d 469, 470. 

City of Mobile vs. McCIure, 221 Ala. 51, 127 So. 832, 835. 

Black's Law Dictionary, 4th edition, p. 917, citing Cross vs. Pas- 

sumpsic Fiber Leather Co., 90 Vt. 397, 98 A. 1010, 1014; Joyce 

v. Missouri & Kansas Telephone Co., Mo. App., 211 S.W. 900, 

901. 

146 P (2) 982 CDist. Ct, of App. 2nd Dist. Dir. 3, Cal. 1944) 

affirmed 25 Cal. (2) 486, 154 P (2) 687 (Sup. Ct. of Cal. 1944). 

28 U.S.C. 2671, et seq., (1946). 

Army Regulations: AR 25-70. 

57 Stat. 372, 1943. 

Army Regulations: AR 25-25, 

50 U.S.C. 738; 28 USC. 2674. 

Army Regulations: AR 27-5. 

28 U.S.C. 2676. 

28 U.S.C. 2671. 

E.D. Ark., 123 F. Supp. 906. 

D.C., Md„ 93 F. Supp. 567. 

225 F. 2d 705. 

171 F. 2d 365, cert, denied 337 U.S. 919. 

103 F. Supp. 543, affirmed 195 F. 2d 494. 

181 F. 2d 723. 

346 U.S. 15. 

350 U.S. 61. 

350 U.S. 907, affirming D.C. Cir., 221 F. 2d 62. 

340 U.S. 135 (1950). 

178 F. 2d 518, affirming D.C. Mi, 77 F. Supp. 706. 

10 Cir., 178 F. 2d 1. 

Parr v. U.S., D.C, Kan,, 78 F. Supp. 693, affirmed 172 F. 2d 

462. 

63 Stat. 861, 5 U.S.C.A. 757(b); Johansen v. U.S., 343 U.S. 427. 

Footnote 17, supra. 

Public Law 569, 84th Congress, 7 June 1957, 70 Stat. 250. 

31 U.S.C. 224d-224i. 

Army Regulations: AR 25-90. 

TIAS 2846, 19 June 1952. 

TtAS 2492, 28 February 1952, and TIAS 2783, 23 March 1953. 

Finance Convention as amended by Schedule HI to the Paris 

Protocol, 5 May 1955. 

50 U.S.C, app. 2294 (1950). 

Melvin v. Reid (Cal.), 297 Pac. 91; Schuyler v. Curtis, 147 N.Y. 

434; and sec. 138 A. L. R. 22., 

Restat, of Law of Torts, 4. 

Patient's right to privacy. (Medicine and Law section) JAMA 

165: 167-168, Sept. 14, 1957. 

Army Regulations: AR 40-200, paragraph 13. 

Doctor and Patient and the Law by Louis J. Regan, 3d edition, 

pages 86-87. McPosey v. Sisters of the Sorrowful Mother, et al. 

(Okla.) 57 Pac. (2d) 617; Morrow v. Cline (N.C.)., 190 S.E. 

207; Liberty Mutual Ins. Co. v. Lipscomb (Ga.), 192 S.E. 56. 

Court decisions — medical professional liability. (Medicine and 

Law section) JAMA 164: 1349-1357, July 20, 1957. 



U.S. NAVY MEDICAL NEWS LETTER 



WHAT KIND OF LEADERSHIP APPROACH? 



* 



LT Frederick F. Nowak MSC USN ^Instructor in Personnel Records and Personnel 
Management, U.S. Naval School of Hospital Administration, National Naval Medical 
Center, Bethesda, Maryland 20014. 



In the Medical News Letter, Volume 43, Number 4 
of 21 February 1964, there appeared an article entitled 
"Leadership Concept: Hard Versus Soft Management." 
This article is reproduced below. 

"The difference between the good leader, manager or supervisor 
and the run-of-the-mill one is that the good leader makes things 
happen while the other allows things to happen. This is frequently 
referred to as the difference between the traditional, military or 
"hard" management and "soft" management. In "hard" manage- 
ment the leader knows what he wants to have happen and what 
needs to be done to accomplish this mission. In "soft" management 
the leader backs off from responsibility and merely allows things to 
happen. However, there is only one kind of leadership — that conduct 
which induces followership and aids in accomplishment of mission. 
It has to be adapted to the situation. On occasion it may be driving 
— a kick in the seat; other times it may be pulling — inquiring into 
and tapping a person's mental resources. Whichever it is, it requires 
knowledge of human behavior to promote outstanding performance. 

At first blush, the article appeared to be speaking of 
only two types of leadership, autocratic (hard) and 
laissez-faire (soft). Upon re-reading the article, it is 
evident that the more modern concept of leadership is 
included and deserves further amplification. 

Before presenting any personal thoughts concerning 
the modern concept of leadership, I would like to state 
that although the concept of laissez-faire does in fact 
exist, and unfortunately so, I would rather not consider 
this to be a form of leadership. It isn't leadership, it 
is nothing. When the thought of leadership comes to 
mind, a stimulus also comes in mind. If laissez-faire 
is to be considered a stimulus, it is a negative one. 
Such negativism is not the type of leadership the Navy 
is seeking. 

The text on Naval Leadership states that "the best 
methods of naval leadership must simultaneously exist 
in two dissimilar and opposite forms." 1 These two 
forms, authoritarian and democratic, exist and are in- 
cluded in and commonly known as the Theory of Bi- 
formity." 

Why must two dissimilar methods of naval leadership 
exist simultaneously? There is a definite requirement 

* Forwarded to the Medical News Letter by CDR E. L. Van Land- 
ingham Jr., MSC USN-Commanding Officer, U.S. Naval School of 
Hospital Administration, NNMC, Bethesda, Md, 
1 Malcolm E. Wolfe, Commander, U.S. Navy, et a], Naval Leader- 
ship (2nd ed, U.S. Naval Institute, Annapolis, Md., 1959), pp. 
8-10. 
2. Ibid. 



in the Navy for an unquestioning response to authority 
even though this response may at times be unpalatable. 
A man's democratic rights do suffer under this approach 
but the need cannot be denied. 3 

It has been determined that a higher form of motiva- 
tion can be attained by using the democratic approach 
or what has been called by various authors the partici- 
pative approach to leadership. 4 I am certain that the 
need for a higher form of motivation is the desire of 
all leaders, a motivation that permits the individual to 
gain satisfaction from the challenge and accomplish- 
ment of the task before him. 

The problem that exists is to fuse the two dissimilar 
forms of leadership. Missions and objectives must be 
accomplished — goals must be set and met. One of our 
jobs as leaders is to set and accomplish these goals. 
Another one of our jobs is to satisfy the needs of our 
followers. It then seems necessary that we motivate 
our followers in such a manner that their needs are 
satisfied through the attainment of the goal. Research 
has indicated that one method of providing such satis- 
faction of needs even though directed toward the 
established goal is through the use of the democratic, 
participative, or permissive (not to be confused with 
laissez-faire) leadership. Get the followers' ego-involved 
so that they will have a direct interest in the accom- 
plishment of the goal and achieve satisfaction while 
working toward and accomplishing this goal. 

I believe that, for the sake of discussion, delegation 
may be included in participation. There are many 
reasons why leaders will not permit participation. Some 
of these reasons are: the feeling that one can do the 
job much better than others; participation takes too 
long; a lack of decisiveness in the matter; a concern 
that the subordinates may do a better job, thereby, 
endangering one's position; a lack of ability to direct 
others; a lack of confidence in subordinates; a lack of 
proper feed-back for control purposes; and the cal- 
culated risk of taking a chance. This list is not intended 
to be all inclusive. One of the many responsibilities of 



Ibid. 
Ibid. 



U.S. NAVY MEDICAL NEWS LETTER 



the leader is to develop his subordinates. Participation 
is an excellent means for development. This is just 
another reason for the use of the democratic or partici- 
pative form of leadership. 

There are many reasons, and very good ones, for 
the use of the authoritarian form of leadership. The 
need for a positive structure and a single direction of 



purpose is an economic and military necessity. Such a 
need is not denied under certain circumstances but the 
need for participation also cannot be denied. 

Below is a graphic presentation of the two dissimilar 
methods of leadership with graduations and combina- 
tions of each." This portrayal has been slightly modified 
in order to make it more leader-oriented. 



Authoritarian 



Democratic 

Participative 

Permissive 



USE OF AUTHORITY 
(Direction) 



Area of Freedom of Action 
afforded followers (Entropy) 



Leader 


Leader 


Leader 


Leader 


Leader 


Leader 


Leader 


makes 


makes 


presents 


decides. 


asks for 


defines 


permits 


decision 


decision 


decision 


Elicits 


sugges- 


limits 


followers 


and 


and sells 


and 


suggestions. 


tions 


and 


to function 


issues 


decision 


invites 


Decision 


but makes 


followers 


within 


command 


to 


questions 


may be 


decision 


make 


limits 




followers 




changed. 




decisions 


defined by 
leader 



The graphic portrayal, as you may have noticed, does 
not permit complete freedom of action on the part of 
the followers. The leader is still in authority, defining 
the limits within which the followers may have freedom 
of action. At the right of the portrayal the ingredients 
of control and leadership necessary for the accomplish- 
ment of the task are still present but to a much lesser 
degree than indicated to the left of the diagram. The 
same concept applies to the extreme left which indicates 
that authority is not absolute. Authority, like freedom, 
is never without limitations. 

Deciding on the Leadership Pattern 

It is not possible to state which leadership pattern is 
to be followed. There are too many variables involved 
in the ultimate determination. Generally speaking, these 
variables may be classified under the general headings 
of the leader, the followers, and the situation that exists 
at a particular moment." 

The Leader. A leader's behavior under any circum- 
stances is in part influenced by his own personality. 
Over the years an individual develops a value system of 
his own and he will act in such a manner as to best 
maintain his system of values. Perhaps he is naturally 
dominant and is comfortable in the leadership role only 
when he is acting in an autocratic manner. He may not 
be comfortable having others make decisions for which 

5. Robert Tannenbaum an<f Warren H. Schmidt, "How to Choose a 
Leadership Pattern," Harvard Business Review, Vol, 36, No. 2, 
March-April IMS, pp. 95-101. 

6. Ibid. 



he is ultimately responsible. There may be a feeling 
of uncertainty because of his knowledge of and confi- 
dence in his subordinates. 

The Follower. Some followers have a definite need 
for freedom and independence to make decisions; 
whereas, others require and desire a more autocratic 
leadership. Not all followers are capable of assuming 
the responsibility of decision-making, possibly because 
of the lack of necessary knowledge and experience to 
deal with problems of a particular nature. Permitting 
a man to make a decision when he has been oriented in 
an autocratic environment may be quite traumatic. The 
same trauma may appear when one who has had free- 
dom and independence in decision-making is put into a 
very structured, directive, and autocratic environment. 
The Situation. The type of leadership demonstrated 
is also influenced by the type of organization, the lead- 
ership approach practiced by the immediate superiors, 
the nature of the group to be led, the nature of the 
problem, and the constantly demanding factor of time. 
The Navy is basically an autocratic organization. 
Autocratic leadership is under many circumstances de- 
sired, required, and condoned. A leader has a tendency 
to act in a manner which is expected by the organiza- 
tion. Tied in closely with the organization is the leader- 
ship behavior exhibited by the immediate superior. If 
the immediate superior is autocratic, there is a tendency 
for the follower of that superior officer to act in the 
same manner. The inverse is also true if the superior 
is a democratic-type leader. 



U.S. NAVY MEDICAL NEWS LETTER 



The effectiveness of the group is also a variable that 
influences the leadership pattern. A willing, cohesive 
group that has the ability to handle problems effectively 
can be given more latitude than a less willing, less 
cohesive, and less capable group. The latter group 
would require more direction than the former. 

The group acceptance of the goal is another variable. 
The group that accepts the goal as their own may re- 
quire much less supervision than the group that is dis- 
interested in and does not accept the goal as their own. 

The problem itself and the time factor involved may 
determine the amount of freedom permitted. Some 
problems may require immediate and decisive action — 
there is no time for a group conference. Others are not 
so urgent and there is opportunity for participation by 
the group. Also, there are certain problems which, of 
necessity, must be resolved by the leader alone. In 
such cases, decision-making cannot be shared with the 
subordinates. 



These are some of the variables that are working 
interdependently which may determine the type of 
leadership pattern to be followed. What kind of leader- 
ship approach is the best one? Since a higher form of 
motivation can normally be gained by the involvement 
of personnel and the satisfactions that can be derived 
from this involvement, it would appear that the best 
leadership approach would be one which is situated on 
the right of the continuum of the graphic portrayal. 
The prevailing variables would dictate when it would be 
necessary to move to the left, the more autocratic form 
of leadership. Such movement might be interpreted by 
some as a lack of consistency in leadership behavior; 
however, it must be realized that different situations 
will, of necessity, call for various forms of leadership. 
A good leader must be flexible enough to move on the 
continuum but he must also establish for himself a 
general pattern of leadership behavior. 



'ROM THE NOTE BOOK 



AVAILABILITY OF NEUROPSYCHIATRY 
RESIDENCIES IN NAVAL HOSPITALS 

It is the intention of this Branch to apprise inter- 
ested individuals of the availability of a limited number 
of vacancies in the fully approved Navy psychiatric 
residency training program. Each year there are only 
nine openings for Navy psychiatrists beginning at the 
first year level. The Navy hospitals which have resi- 
dency training programs in psychiatry are Bethesda, 
Maryland; Oakland, California; and Philadelphia, Penn- 
sylvania. 

Prospective residents frequently ask the question 
whether any Naval hospital can offer completely satis- 
factory residency training within its own walls and at 
the same time meet the requirements now emphasized 
by the review committees of the various national ap- 
proving and accrediting bodies. The same question 
could be asked of any hospital. The Navy's psychiatric 
residency training program, as necessary, utilizes addi- 
tional psychiatric facilities to round out the training 
program. State psychiatric hospitals are used for gain- 
ing full time experience with chronic hospitalized 
psychotic patients. Full time assignments are also made, 
to gain experience, in neurology, in psychiatric out- 
patient clinics and in child guidance clinics. Extensive 
use is also made of civilian consultants who conduct 
seminars and supervise long term therapy cases. The 
experience gained in the Navy hospitals covers inpatient 
and outpatient psychiatry with the entire diagnostic 
category being covered. Both male and female patients 
of all ages are seen for evaluation and treatment as in- 



dicated. The types of therapy taught and utilized en- 
compass all that are available; for example, individual 
and group psychotherapy, and drug, somatic, group 
activities, occupational and milieu therapies. In addi- 
tion, each residency hospital is located in a metropolitan 
area which has available many psychiatric lectures, 
short courses and medical schools with excellent psychi- 
atric departments. Thus, the availability of academic 
exposure to psychiatric matters is extensive. The Neuro- 
psychiatric Program is further backed up by relevant 
research programs of considerable variety. 

The Surgeon General's Consultant Panel in Neuro- 
psychiatry is composed of the following clinical mem- 
bers. These members are a ready source of assistance 
and guidance in dealing with all facets of Navy neuro- 
psychiatry. 



Francis J. Braceland, M.D, 
Psychiatrist-in-Chief 
The Institute of Living 
200 Retreat Avenue 
Hartford 2, Connecticut 



Howard P. Rome, M.D. 
Head, Psychiatry Section 
Mayo Clinic 
Rochester, Minnesota 
(and President-Elect of the 

American Psychiatric 

Assn.) 



Ewald W. Busse, M.D. 
Chairman, Department of 

Psychiatry 
Duke University Medical 

Center 
Durham, North Carolina 

Augustus S. Rose, M.D. 

Professor of Medicine 
Division of Neurology 
School of Medicine 
The Center for the Health 

Sciences 
Los Angeles, Calif. 90024 



U.S. NAVY MEDICAL NEWS LETTER 



Cecil L. Wittson, M.D. 

Dean, College of Medicine, and 

Chairman, Department of Neurology and Psychiatry 

University of Nebraska 

College of Medicine 

602 South 44th Avenue 

Omaha 5, Nebraska 

A copy of a. recent Navy NP Newsletter can be ob- 
tained by writing to this office. This generally reports 
what was accomplished this past fiscal year and part 
of what is planned for the coming year and will give 
you further details regarding the scope of Navy psy- 
chiatry, including some of the current NP research 
studies. 

Applications for residency training are reviewed by 
the Surgeon General's Advisory Board which selects 
residents for training. Although most residencies start 
in July of each year, for some years residents have been 
started in psychiatry at various times of the year vary- 
ing with available vacancies at individual hospitals 
which result from completion of residency training by 
other individuals. Inquiry for further details can be 
made directly to this office. We invite those interested 
to write promptly to: 

Neuropsychiatry Branch (Code 313) 
Bureau of Medicine and Surgery 
Navy Department 
Washington, D.C. 20390 

ACOG ANNUAL CLINICAL MEETING 

The annual Clinical Meeting of the American Col- 
lege of Obstetricians and Gynecologists will be held in 
San Francisco, California, 5-8 April 1965. A special 
air lift to provide transportation between Andrews Air 
Force Base and the U.S. Naval Air Station, Alameda, 
California, has been confirmed with the following 
schedule: 

Depart Andrews Air Force Base 0800, 4 April 1965 
Depart NAS Alameda, California 0800, 9 April 1965 
Medical officers who wish to utilize this air lift should 
forward requests for reservations no later than 1 5 
March 1965 to Director, Professional Division, Bureau 
of Medicine and Surgery. 

AMERICAN BOARD OF OBSTETRICS 
AND GYNECOLOGY 

The Part II examination will be conducted by the 
American Board of Obstetrics and Gynecology at The 
Edgewater Beach Hotel, Chicago, Illinois April 26-May 
1, 1965. Candidates scheduled for examination are 
urged to make their hotel reservations at an early date. 

Applications for the Part II examination to be given 
in April of 1966 will be accepted in the office of the 
Secretary during April or May, 1965 and must be ac- 
companied by duplicate lists of patients dismissed from 



their service during the 12 months immediately preced- 
ing date of application. 

Current Bulletins outlining present requirements and 
application forms may be obtained by writing to the 
office of the Secretary. Applicants are urged to famil- 
iarize themselves with the new rules and regulations 
covering the new schedule of examination which goes 
into effect this year. 

Diplomates of this Board are requested to keep the 
Board office informed of their current address. 

Clyde L. Randall, M.D. 
Secretary and Treasurer 
American Board of Obstetrics and 

Gynecology 
100 Meadow Road 
Buffalo, New York 14216 

OPHTHALMIC PATHOLOGY COURSE 

An additional course in Ophthalmic Pathology will 
be conducted in Fiscal Year 1965 at the Armed Forces 
Institute of Pathology, Washington, D.C, from 12 
April through 16 April 1965. 

Officers desiring to attend should submit their re- 
quests, in accordance with BUMED INST. 1520.8A, to 
this Bureau, Attention: Code 316, as soon as possible. 
Early submission is necessary in order to comply with 
the Army's request to return unused quotas 6 weeks in 
advance of the convening date. 

AMERICAN COLLEGE OF PHYSICIANS 
ANNUAL MEETING 

This Annual Meeting will be held in Chicago, Illinois 
on 22 through 26 March 1965. A special air lift de- 
parting Andrews Air Force Base, Washington, D.C. at 
1200 hours on 21 March and returning at 0800 hours 
on 27 March from Glenview, Illinois is scheduled to 
accommodate medical officers of the Armed Forces 
who desire to attend this meeting. 

Interested medical officers should forward requests 
by message for reservations immediately to: Director, 
Professional Division, BuMed. 

NAVAL MEDICAL RESEARCH REPORTS 

US. Naval Medical Research Institute, NNMC, Be- 
th esda, Md. 

1. Behavioral Contagion: MR 005. 12-2005.01 Report 
No. 2. 

2. Long-Term Intraoral Findings in Humans After 
Exposure to Total-Body Irradiation from Sudden 
Radioactive Fallout. I. Five Year Postdetonation 
Studies: MR 005. 12-5300.01 Report No. 1, Jan- 
uary 1964. 

3. Nematode Parasites From Mammals Taken on 
Taiwan (Formosa) And Its Offshore Islands: MR 
005.09-1606.01 Report No. 14, February 1964. 



8 



U.S. NAVY MEDICAL NEWS LETTER 



4. Digenetic Trematodes of Fishes From Palawan 
Island, Philippines. Part I. Families Acanfhocolpi- 
Angiodictyidae, Cryptogonimidae, Fellodistomidae 
and Gyliauchenidae: MR 005.09-1606.01 Report 
No. 12, April 1964. 



5. The Effect of Temperature and Hematocrit on the 
Viscosity of Blood: MR 005.02-0020.01 Report 
No. 3, June 1964. 

6. Structure Vs. Toxicologic Parameters in New Esters 
of Tropine and ty -Tropine. VI. : MR 005.06-0010. 
01 Report No. 32, July 1964. 



DENTAL SECTION 



PULPAL REACTIONS TO CARIES* 

Sadahiro Yoshida and Maury Massler, Dental 
Abstracts 9(9): 551-553, September 1964. 

Active and arrested caries of the dentin show im- 
portant differences in ground and decalcified sections, 
a histologic study of 98 teeth reveals. 

In the active lesion, the ground section shows a sur- 
face necrotic layer which appears soft, light brown, 
cheesy and structureless. Below this layer always ap- 
pears a wide, yellowish, decalcified layer. Sclerotic 
dentin usually is absent or present in an extremely thin 
layer under the decalcified layer. In the decalcified 
sections of active lesions, the necrotic layer is hema- 
toxylinophilic and not sharply demarcated from the 
underlying decalcified layer. The decalcified dentin 
contains tubules with basophilic granules, transverse 
fissures and ampule-shaped cavitations. 

In the arrested lesion, the ground section reveals a 
thin or absent necrotic layer. The layer immediately 
below is hard, leathery and heavily pigmented. A 
prominent, white sclerotic layer always is present un- 
der the pigmentation. In the decalcified sections of 
arrested caries, the necrotic layer is absent or, if pres- 
ent, is a thin, amorphous, faintly hematoxylinophilic 
material clearly separated from the dentin layer below. 
The pigmented zone usually is free of basophilic gran- 
ules. No sclerotic zone can be distinguished. 

No odontoblastic or pulpal responses were observed 
under enamel caries. Under active lesions, a baso- 
philic line appears at an early stage along the pulpal 
border of the primary dentin. Under arrested lesions, 
this line or stripe is found at the junction of the primary 
and reparative dentin. 

The pulpodentinal membrane subjacent to the lesion 
often is absent or interrupted, especially during the ac- 
tive stage of the carious attack. 

Reparative dentin matrix appears to form during the 
early stage of dentinal caries. Little additional repar- 
ative dentin is formed during the later stages of ar- 

* Copyright by the American Dental Association. Reprinted by per- 
mission. 



rested caries. Odontoblasts subjacent to the reparative 
dentin under the arrested lesions are inactive, degen- 
erated, atrophied or absent. 

The human dental pulp shows a high reparative po- 
tential. The amount of reparative dentin formed can 
be correlated with the depth of the carious lesion. The 
carious process shows a greater tendency to extend 
along the junction between primary and reparative den- 
tin rather than to penetrate directly through the repar- 
ative dentin into the pulp. Except under deep dentinal 
caries, the pulp tissue of most teeth shows no pro- 
nounced inflammatory changes. 

EFFECTIVENESS OF COPAL RESIN VARNISH 
UNDER AMALGAM RESTORATIONS* 

D. Barber, J. Lyell, and M. Massler, Dental 
Abstracts 9(9): 562, September 1964. 

When copal resin varnish is flooded into a prepared 
cavity so that it covers the walls as well as the floor 
of simple and compound amalgam restorations, the 
varnish completely seals the margins of the restoration 
against the penetration of ionic and molecular tracers. 
How long such a seal remains effective is not known. 

Cavities were prepared in freshly extracted cuspids, 
bicuspids and molars. In the control Group I, Class V 
and Class II preparations were restored immediately 
with no copal resin varnish. In the teeth in Group II, 
varnish was used only on the floor (axial wall), and the 
Class V cavity preparations filled with silver amalgam. 
In the Group III teeth, Class V cavities were prepared 
and copal resin varnish was flooded into the cavity to 
cover the walls and floor, after which silver amalgam 
was condensed into the cavity. 

Class II cavity preparations also were lined with 
copal resin varnish, either by flooding the entire cavity 
with the varnish, or by placing the varnish on only one 
proximal surface of an MOD preparation before resto- 
ration. 

The roots of the teeth were covered with wax and the 
teeth were immersed in S"' as sodium sulfate or Ca 45 as 



* Copyright by the American Dental Association, 
mission. 



Reprinted by per- 



U.S. NAVY MEDICAL NEWS LETTER 



calcium chloride, or a dye tracer (a 3.18 per cent 
solution of toluidine blue) was used. After immersion 
for one week the teeth were sectioned longitudinally 
and examined autoradiographically. 

In the control group (Group I) teeth, dye and iso- 
tope tracers had penetrated into all margins of the 
restorations to the floor of the cavity only. The cavities 
in Group III teeth which were flooded with the copal 
resin varnish showed a complete absence of dye or 
isotope penetration. Compound cavities with varnish 
on one proximal surface showed a complete lack of 
isotope or dye penetration on the varnished side, but 
the unvarnished side showed deep penetration. In vivo 
clinical testing is in progress to determine how long the 
varnish is effective as a sealer. 

R. W. Phillips, research professor in dental materials 
at Indiana University School of Dentistry, comments 
as follows: 

"Evidence accumulates to indicate that cavity var- 
nishes serve a useful role in restorative dentistry. How- 
ever, certain of the variables associated with their use 
need further investigation. One of those facets has been 
explored in this report. The results of this study clearly 
indicate that a continuous coating of the varnish over 
the entire cavity preparation is essential if maximum 
protection against the seepage of deleterious agents is 
to be attained. Although for the purpose of the study 
the investigators "flooded" the cavity preparation with 
the varnish in order to assure a complete coverage of 
all surfaces, it should not be inferred that the clinical 
application of a varnish is not to be done delicately. 
Gross excesses at the margins prevent proper finishing 
of the amalgam tooth margin. Likewise, the varnish 
should be applied in several thin coatings, not as a 
thick, viscous single layer. A better seal is attained 
with several thin coatings than by a thick consistency 
varnish. If the varnish becomes viscous it should be 
thinned by an appropriate solvent. 

"The authors properly emphasize that further in vivo 
testing will be required to determine if the exceptional 
seal provided by the varnish deteriorates at the exposed 
marginal areas. Observations in several well-controlled 
dental practices have shown no apparent breakdown in 
this area after as long as eight years of clinical service. 
However, further documentation is necessary. 

"Although this research indicates that with the amal- 
gam restoration it might actually be advantageous to 
bring the varnish to the margins of the cavity prepara- 
tion, a comparable conclusion does not necessarily fol- 
low with all other restorative materials. For example, 
it is known that the varnish is especially valuable to the 
silicate restoration as it minimizes the penetration of 
acid from the silicate gel into dentin. However, in this 
instance it may be desirable to remove the varnish from 
the margins so that the complete effect of the fluoride 
in the silicate may be attained. The presence of the 
varnish at the critical marginal areas does inhibit some- 
what the reaction of the fluoride with tooth structure 



and thus prevents maximum reduction in enamel solu- 
bility. 

"This research corroborates previous studies in this 
field and fills a void relative to the correct clinical usage 
of cavity varnishes." 

EFFECT OF POWERED TOOTHBRUSHING 

PLUS INTER-DENTAL STIMULATION UPON 

THE SEVERITY OF GINGIVITIS 

Irving Glickman DMD, Richard Petralis DDS, and 

Robert M. Marks DDS, Jour Periodont 35(6): 69-74, 

November-December 1964. 

The introduction of automatic toothbrushes has fo- 
cused attention upon toothbrushing and interdental 
stimulation in terms of gingival health. Numerous in- 
vestigations have reported more beneficial effects with 
the automatic toothbrush than with the hand tooth- 
brush, but the findings have not met with universal 
acceptance. Because of the interest in this phase of 
periodontics, a clinical study was conducted to com- 
pare the effect of powered toothbrushing with powered 
toothbrushing plus interdental stimulation upon the 
condition of the interdental gingival papillae. The study 
showed that powered toothbrushing with the use of an 
interdental stimulator adapted for the powered tooth- 
brush reduced the severity of interdental gingival in- 
flammation by an average of 26.3%. 

Powered toothbrushing plus interdental stimulation 
was equally effective on the maxilla and mandible ex- 
cept for the lingual surface of the mandible. Greatest 
improvement in the gingival condition following pow- 
ered toothbrushing plus interdental stimulation occurred 
on the facial surface of the mandibular right posterior 
area; least reduction in gingival inflammation occurred 
on the lingual surface of the mandibular left posterior 
area. 

The maximum difference between the percentage re- 
duction in interdental gingivitis following powered 
toothbrushing alone as compared with powered tooth- 
brushing plus interdental stimulation occurred on the 
lingual surface of the mandibular anterior segment. 
In this area gingivitis was reduced 26.3% following 
powered toothbrushing plus interdental stimulation and 
1,4% following powered toothbrushing alone. 

It was not established whether the effects of tooth- 
brushing and interdental stimulation are derived from 
cleansing action or massaging or both. 

EXTRADIETARY FLUORIDE 
SU PPLEMENTATION * 

Richard E. Jennings and Robert T. Culpepper, 
Dental Abstracts 9(9): 581, September 1964. 

The effect of supplemental fluoride in combination 
with other compounds on either caries or enamel mot- 



' Copyright by the American Dental Association. Reprinted by per- 
mission. 



10 



U.S. NAVY MEDICAL NEWS LETTER 



tling cannot be predicated. Strong motivation on behalf 
of both parents is necessary to dispense supplemental 
fluoride properly over a long period and to prevent ex- 
cessive consumption. Supplemental fluoride prepara- 
tions cannot be considered a satisfactory substitute for 
either the consumption of fluoridated water or the ap- 
plication of a concentrated topical fluoride to the teeth 
in the dental office. 

As noted by Hennon and Muhler (1962), caution is 
necessary in anticipating results to be obtained from 
extradietary fluoride administration when comparing 
such administration to a fluoridated public water sup- 
ply, since the two methods differ drastically. Even 
though it is possible to ingest the same total amount 
of fluoride each day from either source, the duration 
of blood availability and the peaking of fluoride ions in 
the blood undoubtedly are different. In a quart of 
drinking water fluoridated to 1.0 mg. per liter, a child 
would consume 1.0 mg. of the fluoride ion in small 
doses over a long period. If 1 mg. of fluoride were 
ingested in a single dose, it would be rapidly eliminated 
by the kidneys, with only a transitory amount available 
to the developing teeth. 



Consumption of fluoride from a fluoridated water 
source supplies fluoride to the body during various 
periods of the day and maintains a more constant blood 
level. Also, it increases the food fluoride content since 
fluoridated water is used in the preparation of the 
meals. Studies on both animals and human beings show 
that the fluoride tablet taken once daily does not dupli- 
cate the blood picture of one drinking fluoridated water, 
and as a result may not duplicate the decay preventive 
effect in the teeth. 

The effect of a fiuoride-multivitamin preparation on 
caries has not been investigated in children but, in ex- 
periments in the monkey, there are indications that 
vitamins A, C, and D influence fluoride metabolism. 
Thus, the physician who prescribes vitamin prepara- 
tions containing fluoride cannot be assured that the 
fluoride will be effective nor can he predict the effect 
on enamel appearance (mottling). 

Any fixed combinations of fluoride with other nutri- 
ents increase the difficulty of adjusting the prescribed 
fluoride to allow for fluoride levels already in the 
child's drinking water, since alterations of the dose 
also will alter the vitamin intake. 



DENTAL X-RAY EXPOSURE OF SITES WITHIN THE HEAD AND NECK 



A. G. Richards MS, Ann Arbor, Michigan and R. L. Webber DDS, San Francisco, 
Calif., Oral Surg, Oral Med, and Oral Path, 18(6): 752-756, December 1964. 



The article cites an investigation carried out to de- 
termine the amount of radiation to which selected 
sites within the patient's head and neck are exposed 
during posterior bitewing and periapical X-ray exam- 
inations. The results, shown in the tables that follow, 



indicate that, with few exceptions, the exposures made 
with 65 and 90 KVP were comparable, and that all 
were relatively low compared with earlier studies re- 
ported in the dental literature. 



POSTERIOR BITEWING 



65 KVP 



90 KVP 



Organ 



Lens of eye 

Anterior tongue at midline 
Posterior tongue at midline 
Submaxillary gland 
Parotid gland 
Pharyngeal tonsil 
Pituitary gland 
Thyroid gland 
Spinal cord 



Exposure 
organ (m 


of 

r) 


Per cent of 
total exposure 


Exposure of 
organ (mr) 


Per cent ot 
total exposure 


28.0 


0.8 


27.0 


1.0 


333.0 




10.1 


330.0 


12.5 


221.0 




6.7 


236.0 


8.9 


60.0 




1.8 


81.0 


3,1 


42.0 




1.3 


50.0 


1.9 


62.0 




1.9 


82.0 


3.1 


15.0 




0.5 


32.0 


1.2 


39.0 




1.2 


44.0 


1.7 


8.0 




0.2 


13.0 


0.5 



U.S. NAVY MEDICAL NEWS LETTER 



! ! 



PERIAPICAL X-RAY 



65 KVP 



90 KVP 



Organ 



Exposure of 

organ (mr) 



Per cent of 
total exposure 



Exposure of 

organ (mr) 



Per cent of 
total exposure 



Lens of eye 

Anterior tongue at midline 
Posterior tongue at midline 
Submaxillary gland 
Parotid gland 
Pharyngeal tonsil 
Pituitary gland 
Thyroid gland 
Spinal cord 



77.0 


2.1 


79.0 


2.6 


427.0 


11.5 


429.0 


14.2 


222.0 


6.0 


226.0 


7.4 


79.0 


2.1 


78.0 


2.6 


37.5 


1.0 


35.0 


1.2 


111.0 


2.9 


iio.o 


3.7 


56.0 


1.0 


36.0 


1.9 


49.0 


1.3 


48.0 


1.6 


16.0 


0.3 


12.0 


0.5 



PERSONNEL AND PROFESSIONAL NOTES 



Policy on Ultrasonic Instrumentation in Periodontal 
Therapy and Oral Prophylaxis. The Dentsply-Cavitron 
Ultrasonic Dental Unit, FSN 6520-890-1584, is avail- 
able to naval dental activities. Due to early reports of 
potential oral tissue damage from this instrument, Bu- 
Med policy has limited its use to dental officers with 
special training. 

A recent thorough review of the published literature 
(U.S. Navy Medical News Letter 44(12): 12, 25 Dec 
1964) indicated that no significant injury occurs when 
this instrument is used with appropriate knowledge, 
care, and skill. The bulk of evidence indicates that 
this instrument is an excellent adjunct to periodontal 
therapy. The evidence also justifies authorization of 
properly trained and supervised dental technicians to 
use this instrument for removal of supragingival cal- 
culus. 

Appropriate special training in use of this instru- 
ment is available in the five-day course in "Perio- 
dontics" given at the Naval Dental School. Comparable 
special training is also offered at some civilian dental 
schools in the form of short postgraduate courses and 
may be supported by BuMed funds. 

Appropriate formal training for dental technicians 
is not available. To date, such training is available 
only from local dental officers who are so trained. It 
is emphasized that the supervising dental officer will 
always be responsible for the patient care performed 
by his auxiliary personnel. 

Dental Corps Contributes to International Relations. 
A recent issue of The Observer, published by MACV, 
for U.S. Forces in Vietnam, carried an article on fabri- 
cation of artificial eyes at the Cong Hoa Hospital in 
Saigon. Development of this program is an excellent 
example of the manner in which CAPT Glen D. Rich- 
ardson DC USN has contributed to international rela- 
tions, as well as to the health and well-being of allies, 



by transmitting to allied officers the knowledge and 
skills gained from U.S. Navy Dental Corps training 
programs. 

Until last August, the only prosthetic eyes available 
in Vietnam were imported from Japan. CAPT Rich- 
ardson, stationed at Headquarters Support Activity, 
Saigon, noted that several wounded soldiers at the 
Cong Hoa Hospital were missing eyes. CAPT Rich- 
ardson made known to the hospital authorities that 
both he and his prosthetic laboratory technician, DTI 
Gradie K. Maness, had been trained in maxillofacial 
prosthetic technics at the U.S. Naval Dental School, 
National Naval Medical Center, Bethesda, Maryland. 
Upon request of the hospital authorities, CAPT. Rich- 
ardson initiated a part-time training program for the 
dental staff, headed by CAPT Nguyen Van Dom, in 
February 1964. Since August, over 35 patients have 
been fitted with eye prostheses by the Vietnamese den- 
tal staff. The technic for fabrication of artificial eyes 
and other maxillofacial prosthetic appliances by the 
adaptation of dental prosthetic materials and methods 
was developed at the U.S. Naval Dental School during 
World War II and the years immediately following. 
Many World War II eye casualties were treated. Dur- 
ing recent years, the Navy Dental Corps has main- 
tained the capability for maxillofacial prosthetic service 
at the U.S. Naval Dental School and at the U.S. Naval 
Hospital, San Diego, California. In 1963 and 1964 
respectively, totals of 376 and 321 maxillofacial pros- 
thetic appliances were fabricated at those two naval 
dental facilities. 

The Navy Dental Corps maintains capabilities in 
these unique technics by means of a continuing training 
program for specially selected prosthodontists and 
prosthetic laboratory technicians at the Naval Dental 
School should the need arise in the event of a national 
emergency. 



12 



U.S. NAVY MEDICAL NEWS LETTER 




(Photo compliments of The Observer. Legend: Viet- 
namese soldier gets artificial eye. Dental officers 
Khang and Richardson at work.) 



Navy Dental Officer Presentations. CAPT Fred L. 
Losee DC USN, Dental Research Officer, U.S. Naval 
Training Center, Great Lakes, Illinois was recently 
invited to present talks before three professional so- 
cieties in Chicago, Illinois. 

On 12 January 1965 he spoke before the Chicago 
Section of the Society for Applied Spectroscopy on 
"Trace Minerals and Dental Caries." On 1 February, 
he presented a talk entitled, "Soil and Its Relation to 
Dental Caries" before the Odontograph Society of Chi- 
cago, and he was invited to present a talk on 24 Feb- 
ruary entitled, "Caries, Cancer, and Coronary Disease 
— Is there a Relationship?" before the Chicago Dental 
Society. 

American-Philippine Dental Seminar Held at Sangley 
Point. CAPT R. F, Erdman DC USN, Dental Officer, 
U.S. Naval Station, Sangley Point, P. I. hosted a dental 
seminar for the Philippine Dental Association in De- 
cember, 1964. 

Those attending the session included Doctor Ursua, 
President of the Philippine Dental Association; Doctor 
Rodriguez, Dean of the Dental School, University of 
the Philippines; COL D. Santos, military representa- 
tive; and presiding officers of the various local chapters 
of the PDA throughout the island of Luzon. Also 
present were U.S. Navy dentists from Subic Bay, San 
Miguel, and Cubi Point. Presentations were made by 
three dental officers of the Sangley Point Naval Station. 
LCDR W. L. Sullivan DC USN presented an illustrated 
paper on the "Amalgam Alloy Restoration." LT E. F. 
McGee DC USN presented a paper on "Preparation 

U.S. NAVY MEDICAL NEWS LETTER 



and Filling of Root Canals," supported by two of the 
Navy Dental Corps training films. LT M. F. O'Halloran 
DC USN presented a "Comparison in Modern Fluori- 
dation Techniques." 

Navy Dentist Honored by Dental Societies. CAPT 
Angus W. Grant DC USN, Executive Officer, U.S. 
Naval Dental Clinic, Long Beach, California recently 
was elected to serve as President of the American 
Academy of Oral Roentgenology for 1965 and is to 
serve as the Vice Chairman for the Section of Oral 
Roentgenology for the 1965 Annual Session of the 
American Dental Association. 

Dental Training Program for Peace Corps Physicians 
is Given Assistance by Navy Dental Corps. The chief 
dental officer of the Peace Corps has announced that 
material and techniques developed in the course for 
submarine medical officers in the management of den- 
tal emergencies have been used in teaching Peace 
Corps physicians. Peace Corps physicians have the 
responsibility of supervising the oral health of the 
volunteers in the field in isolated areas. This respon- 
sibility closely parallels that of the medical officers on 
fleet ballistic missile submarines. It was possible, there- 
fore, for the Submarine Medical Center, Submarine 
Base New London, Groton, Connecticut to give some 
assistance to the Peace Corps dental officer in setting 
up a training program for physicians. The course at 
New London, taught by LCDR W. R. Shitler, DC USN, 
is a regular part of the School of Submarine Medicine 
curriculum. The course consists of eight hours of 
lectures, two hours of practical training in manipula- 
tion of materials, and ten hours of rotating clinical 
observation. The clinical periods are given at the 
Submarine Base Dental Department. CAPT G. O. 
Stead is the Submarine Base Dental Officer. 

Disposition of Dependent Dental Records. Change 
Number 1 to SECNAVINST P-52I2.5B, Disposal of 
Navy and Marine Corps Records, authorizes the de- 
struction of dependents dental health record jackets, 
including SF-603 and roentgenographs, two years after 
sponsor has been detached from local duty station. 

Reserve Dental Officers Participate in Casualty Care 
Training. CAPT. G. R. Shaver DC USN, ELEVENTH 
Naval District Dental Officer, scheduled a Casualty Care 
Program for thirteen Naval Reserve dental officers at 
the U. S. Naval Training Center, San Diego, California 
4-7 December 1964. CDR W. J. Jasper and LT M. C. 
Clegg DC USN instructed the course 'which included 
officers of dental reserve companies 11-1, 11-3, 11-4, 
1 1-5 and two active duty dental officers. 

Naval Dental School Sends 32 Technicians to the Fleet. 
Certificates for successful completion of advanced and 
specialized training courses in the Enlisted Schools of 
the U. S. Naval Dental School were awarded to thirty- 
two dental technicians at graduation exercises on 18 

13 



December in the Main Auditorium, National Naval 
Medical Center, Bethesda, Maryland. 

"An Extra Pair of Hands" was the theme of an ad- 
dress to the graduates by CAPT William R. Stanmeyer 
DC USN, Staff Dental Officer, Severn River Naval 
Command, and the Dental Officer, U. S. Naval Acad- 
emy, Annapolis, Maryland. 

CAPT A. R. Frechette DC USN, Commanding Of- 
ficer of the U. S, Naval Dental School, presented letters 
of commendation to those students with the highest 
averages in their respective fields of dental technology: 
Donald G. Woolridge DTI, Advanced General; Stanley 
J. Richings DTC, Advanced Prosthetics; and Robert S. 
Weldy DT2, Basic Repair. 

Eldor R. Oien DT2, received the ninth Thomas 
Andrew Christensen Award in recognition of his loyalty 



and devotion to duty in the U. S. Navy. Established by 
the Naval Dental School to honor the only naval dental- 
man posthumously presented the Navy Cross for extra- 
ordinary heroism, the award is presented, from time to 
time, to a graduate of an enlisted school who is chosen 
on the basis of his service record and service reputation. 

RADM Frank M. Kyes, Assistant Chief of the 
Bureau of Medicine and Surgery (Dentistry) and Chief 
of the Dental Division, assisted by CAPT R. R. Trox- 
ell DC USN, Head of the Enlisted Education Depart- 
ment, awarded certificates to twenty graduates of the 
Advanced General School, ten of the Advanced Pros- 
thetic School, and two of the Basic Repair School. 

Music was provided by the String Ensemble of the 
Marine Band under the direction of MGY-SGT William 
Rusinak. 



AVIATION MEDICINE SECTION 




MEDICAL ASPECTS OF OPERATION SEA ORBIT, THE 

FIRST AROUND-THE-WORLD CRUISE BY NUCLEAR 

POWERED SURFACE SHIPS* 

CDR F. H. Austin, Jr. MC USN, Medical Officer, USS Enterprise (CVA(N)65) and 
TF-ONE, F.P.O., New York, N. Y. 09501. 



Introduction 



Task Force One formed at I200Z on 3) July 1964 
under the command of RADM B. M. Strean, U. S. 
Navy. The force was composed of the three nuclear 
powered ships, USS Enterprise (CVA(N)65), USS 
Long Beach (CG(N)9), and USS Bainbridge (DLG- 
(N)25). fts mission was to conduct an around the 
world cruise (over 30,000 miles) in sixty five days 
without logistic support. 

The force departed the Straits of Gibraltar and took 
a route south down the west coast of Africa, around 
the Cape of Good Hope, north up the east coast of 
Africa to Karachi, Pakistan. From Karachi the force 
proceeded down the west coast of India around Ceylon 
then southeast to Freemantle, Australia and eastward 
to Melbourne and Sydney. The final route homeward 
bound departing Sydney and Wellington, New Zealand 
crossed the South Pacific, rounded Cape Horn, pro- 
ceeded up the east coast of South America, stopping at 
Rio de Janeiro, and from there to Norfolk, Virginia. 

The primary overall objectives of Operation Sea 
Orbit were to test the capability of these ships to 
cruise at high speed indefinitely in all environments of 
the sea and weather without replenishment of any kind 

* This article is an unclassified rewrite of the Medical Chapter con- 
tained in Commander Task Force One's Sea Orbit Cruise Report 
of 3 October 1964. 



and to show the ships and their aircraft to the peoples 
of countries along the way. Several secondary objec- 
tives were also realized. 

Medical Considerations 

The Medical Department's view of Sea Orbit focused 
on the concept of a relatively extended cruise with long 
at-sea periods and short in-port liberty (rest and recrea- 
tion) periods. This was combined with visits to un- 
familiar ports and areas of the world, rapid climatic 
changes, and particularly the concept of essential isola- 
tion, in that no stores or supplies (medicine, fresh 
provisions, etc.) would be received and no medical 
evacuation utilized. 

The cruise began 31 July 1964 from the Straits of 
Gibraltar and terminated in Norfolk, Virginia on 3 
October 1964 (64 days). The ports of call were: 
Karachi, Pakistan; Sydney, Australia; and Rio de 
Janeiro, Brazil (Enterprise); Karachi; Freemantle, Au- 
stralia; Wellington, New Zealand, and Rio (Bainbridge): 
Karachi, Melbourne, Austrialia: Wellington and Rio 
(Long Beach). 

The complement of officers and crew of Enterprise 
was 4,244, Long Beach 941, and Bainbridge 421. En- 
terprise had six (6) Medical Officers aboard, Long 
Beach and Bainbridge had one each, The Medical Of- 



14 



U.S. NAVY MEDICAL NEWS LETTER 



UpcfNTERPRISL 




OPERATION SEA ORBIT, TASK FORCE ONE MEDICAL STAFF: (L to R) Drs 
Jim Snyder, Stuart Fleming, Cary Hodnett, Mario Rosa-Garcia, R. Bendixen, Frank 
A-ustin, Ben Jenkins (MSC), Don Gaylor and Hal Cotnpton. (Official Photograph, 

U. S. Navy.) 



ficer of Enterprise served TAD as TF-ONE Medical 
Officer. Three all-force Medical conferences were held 
aboard Enterprise during the cruise, for the exchanging 
of medical intelligence and for professional stimulus. 
Medical officers from accompanying ships were trans- 
ferred by helicopter. 

Discussion 

General Considerations, The planning and logistics 
for Sea Orbit began early in the normal Mediterranean 
deployment when the cruise was first proposed. The 
drug and material requirements for the additional 65 
days underway were well within the normal reserve 
held aboard each ship. All supplies were rechecked 
against up-dated usage rates, anticipating an increase 
in elective surgery and dental care, due to the pro- 
tracted at-sea period. All needed supplies were obtained 
through normal channels by the last at-sea replenish- 
ment period. 

The only additional immunization requirement over 
those necessary for the Mediterranean was a cholera 
booster. All hands on Enterprise were scheduled for 
this shot during the Naples in-port period in order to 
utilize the immunization gun of PMU-7. Long Beach 



and Bainhridge utilized needles. Stragglers were im- 
munized thereafter and records screened on all per- 
sonnel for currency of immunizations. As usual this 
program proved to be protracted and frustrating until 
all hands were current, both with immunizations and 
their record cards. 

Psychiatric problems and morale factors were not 
unusual in numbers or. degree, but as expected they 
occupied a good deal of the Medical Department's time 
along with the Chaplain's and Personnel Offices. Just 
prior to outchop, several requests from the Red Cross 
required evaluating to judge emergency leave justifi- 
cation. The prospect of an added two months to the 
normal deployment evoked some distress among a few 
personnel and/ or their dependents. In most cases these 
problems worked out satisfactorily without leave. After 
the cruise was underway and isolation made emergency 
leave impractical, all personnel settled down to the 
serious job at hand. 

Advanced medical information on the ports to be 
visited was obtained from Preventive Medicine TJnit-7, 
Naples, COMMIDEASTFOR, CINCLANTFLEET and 
from the ALUSNAs concerned. The preventive medi- 
cine problems of concern were endemic Malaria in 



U.S. NAVY MEDICAL NEWS LETTER 



15 



tropical Africa areas, (involved only the liaison and 

C.O.D. crews), enteric disease hazards in Karachi, and 
the Yellow Fever, Malaria, enteric disease and venereal 
disease risks of South American ports. Personnel were 
indoctrinated concerning the hazards from contaminated 
food and drink and mosquito-borne diseases. The in- 
tensive command and medical programs relative to 
venereal disease education and prevention were con- 
tinued during Sea Orbit. The incidence of all diseases 
was low, probably attributable mostly to the short 
liberty visits and thus the reduced exposure. 

Transit, Phase One. No significant medical or surgi- 
cal problems were encountered in transit around Africa 
and into Karachi. The advanced liaison parties and 
all C.O.D. Aircraft crews were begun on malaria pro- 
phylaxis utilizing one combined chloroquine — prima- 
quine tablet once per week in accordance with 
BUMEDINST 6230.1 1C. 

The aircraft (CIA's), returning aboard from all air- 
ports were sealed and sprayed to kill insects. 

On 4 August, at sea off Liberia, a GMCS aboard 
Bainbridge died of myocardial infarction. His remains 
were transported by helo to Enterprise, prepared by a 
licensed embalmer and air evacuated by CIA to Roberts 
Field, Monrovia for air shipment home. ALUSNA, 
Monrovia arranged details for the remains (and escort) 
which arrived in Charleston, S. C. on 8 August, thus 
greatly relieving the stress on the next of kin. The 
remains could have been retained aboard for burial at 
sea or return to CON US had this been an operational 
necessity. 

The first all-force Medical Conference was held on 
12 August and anticipated problems of the Karachi port 
visit discussed. 

On 19 August the advanced party was flown into 
Mauripur Airport, Karachi and several personnel, in- 
cluding the disbursing officer and pilots were quar- 
antined because of "improper medical shot records." 
It was subsequently learned that the health officers had 
questioned the absence of a certification stamp over 
the Medical Officer's signature, especially for yellow 
fever. This stamp is required on the International Cer- 
tificate, PHS Form 731, but is specifically not required 
for the Military Form 737 (white card) in accordance 
with BUMEDINST 6230. ID. However, in order to 
avoid further difficulties, all personnel going to the air- 
port thereafter were issued International Cards and DD 
Form 737 entries for Smallpox, Cholera, and Yellow 
Fever were all stamped. It is considered advisable for 
crews flying into International airports to possess a 
PHS Form 731 (yellow card) as well as the DD Form 
737, the entries of which have been properly signed 
and stamped. 

Port Visit, Karachi (20-21 August), Bainbridge 
moored alongside a pier while Long Beach and Enter- 
prise anchored out. The rough seas restricted boating 
and limited the liberty party to a total of approximately 



2,500 personnel from the three ships for the day and a 
half available. 

Eight doctors from the Basic Science Medical In- 
stitute (operated on aid by the University of Indiana) 
at Jinnah Hospital were invited in advance and visited 
Bainbridge and Enterprise on 21 August. Dr. Harold 
Margulies, the Director from University of Indiana, 
was accompanied by three other United States and 
four Pakistani doctors. 

The Pakistan Director of Naval Medical Services, 
Commodore S.H.A. Gardezi, hosted the Medical 
Officers to lunch and a tour of the Naval Hospital 
facilities. 

Personnel going on normal liberty were considered 
by TF-ONE Medical Officer to be at minimal risk 
from malaria. However, instructions dictated that 
chemoprophylaxis be given. This was accomplished by 
administering one tablet of combined chloroquine- 
primaquine 48 hours prior to port entry so that possible 
enteric upsets would not be confused with diarrhea 
which might be the result of eating and drinking ashore. 
All Karachi Medical personnel consulted were of the 
opinion that the risk in metropolitan Karachi for the 
short visit was slight. 

The incidence of enteric disease in the population 
had been diminishing over the last week prior to 
TF-ONE's visit. A minimal number of personnel 
suffered diarrhea following the visit, and no patho- 
genic organisms were cultured. 

Camel saddles and fur hats were purchased at the 
native markets in large numbers by the crews. The 
hats were found to harbor lice and were subsequently 
disinfected with DDT powder. The saddle pads con- 
tained unsterilized raw cotton. These were all unstuffed 
and the cotton discarded so as to avoid problems of 
the importation of this material into CONUS. 

One crewman of Enterprise was bitten on the finger 
by a pet monkey. Because the incidence of rabies was 
reported as high, this man was treated with a course 
of rabies vaccine (duck embryo). No complications 
developed. 

Just prior to port entry, an Enterprise helicopter 
crashed at sea. All four personnel were rescued after 
a few minutes in the water. While attempting salvage, 
skin divers spent about 45 minutes in the water which 
was infested with long, yellow sea snakes, reported to 
be poisonous. No personnel were bitten, but these 
snakes were discussed with Karachi medical personnel 
who confirmed that they were poisonous and that a 
polyvalent antiserum was available at hospitals in 
Karachi. 

The hospitals of Karachi requested blood donors and 
twenty one personnel donated blood ashore. 

Venereal exposure was estimated to be low. One 
case of gonorrhea and one of chancroid were reported. 

Transit, Phase Two, An unusually low number of 
diarrhea cases (15) occurred in the three days follow- 



16 



U.S. NAVY MEDICAL NEWS LETTER 



ing Karachi. The episodes were self-limited, no sec- 
ondary cases occurred and no pathologic organisms 
were cultured. 

The Long Beach Medical Officer performed his sec- 
ond emergency appendectomy of the cruise on 23 
August. 

The second all-force Medical Conference was held 
aboard Enterprise on 26 August. Problem medical 
cases were presented for discussion and professional 
papers given. 

ALUSNA Canberra sent the following message on 
19 August: "GO A Department of Health requires that 
the following statement from Senior Medical Officer 
TF-ONE must be received and acknowledged by Direc- 
tor of Health, Perth, Western Australia prior to takeoff 
of any flights enroute Perth. No quarantinable disease 
on board any ship in TF-ONE including Smallpox, 
Cholera, Yellow Fever, Plague, Typhus and no com- 
municable disease on board. All personnel (Military 
and Civilian) embarked in TF-ONE have been vac- 
cinated against Smallpox. Signed (Name, and Rank of 
Medical Officer). This statement will be considered 
effective for all Australian Port visits and all flights 
landing in Australia from Enterprise. NOTE: A com- 
municable disease will not affect port clearance but 
must be made known to health authorities. Department 
of Health states that they will accept a statement which 
is initiated up to 48 hours prior to ETA of COD air- 
craft". This required Pratique message was sent on 28 
August, Priority/Unclassified, Action ALUSNA CAN- 
BERRA, who passed it to Health Authorities and re- 
layed acknowledgment and clearance. 

Until about 28 August the full range of fresh vege- 
tables was available. Thereafter for another two weeks, 
carrots and celery remained, Then only fresh apples 
and dehydrated, canned, and frozen fruits were avail- 
able. No vitamin deficiencies were anticipated and none 
were seen in the personnel. Supplemental vitamins were 
not deemed necessary and were medically prescribed 
only on an individual case basis. Personnel were en- 
couraged to drink fruit juices and eat the wide variety 
of foods offered. 

Port Visits, Australia and New Zealand. There were 
no preventive medicine problems anticipated from the 
visits to Australia and New Zealand ports. Reception 
of the personnel was overwhelming, and an estimated 
8,205 liberties were made by Enterprise personnel in 
Sydney during the two and a half day visit (4, 5, 6 
September 1964). A similar welcome and percentage 
of liberties were experienced by Long Beach and Bain- 
bridge in Freemantle and Melbourne, Australia and in 
Wellington, New Zealand. 

Only one man was injured in Sydney. This was due 
to an auto accident in which he sustained a lacerated 
lip and moderate concussion. He was well treated at 
Prince Alfred Hospital and released to return to 
Enterprise. 



A young female kangaroo (18 months old) was ac- 
quired from the Taronga Zoological Park, Sydney for 
transportation to the Norfolk Zoo. The Director issued 
a "live stock certificate and declaration" which stated 
that the animal was "free from all infectious and con- 
tagious diseases", and "has not within the next preced- 
ing six months been in direct or indirect contact with 
stock infected with any such diseases". Except for 
some mild diarrhea, perhaps seasickness, and slight 
weight loss, the kangaroo took the trip well aboard 
Enterprise, and presented no health hazard. No quar- 
antine problems were encountered in importing the 
animal into CONUS. 

Transit, Phase Three. No enteric disease outbreaks 
occurred following the Australian and New Zealand 
visits. Venereal disease incidence was low. 

Morale was distinctly boosted by the visits to these 
friendly English speaking countries. 

During this transit, at a longitude of approximately 
40° South, the task force passed through a time zone 
each day, losing an hour each twenty four. This dis- 
ruption of the Circadian Cycle (physiological clock 
mechanism) resulted in fatigue. The crew remained 
busy with training exercises and no major deleterious 
effect was encountered. 

The third all-force Medical Conference was held on 
1 8 September and anticipated problems in South Amer- 
ican ports were discussed. 

A slight increase in non-aviation accidents and in- 
juries was noted. This was attributed in part to high 
winds and rough seas, but emphasis on the ship's 
general safety programs was intensified. 

A medical information report requested from ALUS- 
NA Rio by message arrived with the first mail from 
Montevideo. No information on venereal disease was 
available. From this letter, warnings concerning eating 
of unwashed vegetables were disseminated to the crew, 
as well as the information that the incidence of typhoid 
fever, amebic and bacillary dysentery and hepatitis was 
high. 

The following message was sent to ALUSNA Rio. 
"Pass to port director. ATTN Health Officer. Pratique 
certified TAW Gen Order 20, No international quaran- 
tinable diseases and no other communicable diseases 
aboard any ships TF-ONE. All military and civilian 
personnel have received Smallpox and Yellow Fever 
immunization.. Each ship has a medical officer em- 
barked. Enterprise has on board one kangaroo in pos- 
session of health declaration for absence of disease or 
exposure for six months. Will not land animal. No 
other animals or birds aboard. CDR Frank H. Austin, 
Jr. MC USN, Medical Officer TF-ONE certifies". 

In anticipation of a high venereal disease risk, the 
preport Petty Officers' Venereal Disease Meetings were 
given special emphasis, with the stress being placed on 
hazards of spread into CONUS with only nine days 
to go until arrival. 



U.S. NAVY MEDICAL NEWS LETTER 



17 



Port Visit, Rio de Janeiro (23-24 Sept 1964). No 
problems were encountered with quarantine declara- 
tion. Approximately 2,500 personnel were on liberty 
ashore each of the two days. No significant injuries 
or medical emergencies were encountered. 

The openly accepted custom of street and bar "solici- 
tation" indicated that venereal exposure rate might be 
extremely high. Numerous cases of the various ve- 
nereal diseases were subsequently diagnosed. 

Transit, Phase Four, The first case of gonorrhea 
appeared on the evening of 25 September an incubation 
period of just 48 hours. 

No medical problems were encountered during the 
transit period from Rio to CONUS. The standard 
Pratique message was sent to the Naval Station, Nor- 
folk and advance liaison concerning the kangaroo and 
medical patients for transfer to hospitals was provided. 

One patient on Enterprise was tentatively diagnosed 
as having malaria on 25 September. His symptoms had 
begun on 10 September, twenty days after one day's 
liberty" (exposure?) in Karachi. He had taken one 
combined Chloroquine-primaquine tablet prior to 
liberty. 

Medical Summary 

Operation Sea Orbit offered a unique opportunity 
(the first) for the Health Physics Sections of Task 
Force One to measure the atmospheric radiation levels 
around the world and in both hemispheres. The con- 
tinuous monitoring of the air, "swipe" and water 
samples demonstrated: 

a. That the fall-out levels along the track of Sea 
Orbit are at present negligible. 

b. That radioactive contamination from nuclear 
powered ships is nil. 

Through a visual demonstration, as part of the 
presentation for visitors, the safety of nuclear reactors 
was vividly displayed. 

Surgical Experience: No unusual incidence of surgi- 
cal disease appeared. Enterprise performed five appen- 
dectomies, Long Beach three. Enterprise had six major 
emergency cases (hand and arm traumas), Long Beach 
two, and Bainbridge two. Heavy seas resulted in four 
moderate to severe injuries aboard Long Beach and 
Bainbridge. Enterprise surgeons performed over 148 
elective minor and major surgical procedures during 
the cruise, thus maintaining the Surgical section in a 
high state of readiness. 

Medical Experience: Bainbridge had one death due 
to myocardial infarction and two cases of ureteral ithia- 
sis were seen. Long Beach encountered 105 cases of 
upper respiratory infection in August and 48 cases in 
September. Enterprise reported no unusual prevalence 
of medical diseases. 

Psychiatric Experience: The majority of the crews 
tolerated the isolation and long steaming periods well. 



Long Beach transferred one case diagnosed as Para- 
noid Personality to Enterprise for disposition. The 
usual incidence (5-10 cases per week) of moderate 
anxiety reaction was seen and treated by the various 
Medical Officers. Morale was generally high, with 
some exceptions. These were attributed not so much 
to Sea Orbit, itself, as to the fact that the ships had 
already been deployed for about six months when the 
Operations began. No psychiatric limiting factors to 
the extended operation of a Nuclear Task Force could 
be anticipated from the experience of Sea Orbit, ex- 
cept that careful personnel screening, of the nature 
used for Antarctic wintering-over parties, would reduce 
the numbers and severity of problem cases. 

Preventive Medicine Experience: All immunization 
records were screened, with special attention being 
given to cholera and yellow fever. No personnel con- 
tracted any non-venereal communicable disease ashore. 
The Karachi visit yielded approximately 20 cases of 
gastroenteritis on the three ships, with no specific patho- 
genic organisms being cultured, and no secondary cases 
developing. Venereal disease incidence was low from 
Karachi (1) and Australia/ New Zealand (II). The 
final figures for Rio de Janeiro surpass 40 cases. Sev- 
eral cases of gonorrhea with an incubation period of 
only 48 hours developed following this port visit. 

Aviation Medicine Experience: Two aircraft were 
lost during the cruise with all personnel being recov- 
ered. Both were due to material failure, a UH2A 
on 20 August and an A5A on 27 September. The Air 
Group flew 18 fire power demonstrations and 8 fly 
overs and had 9 days of limited flight operations for 
training and test. The reduced operating pace caused 
no major difficulties. The need for assuring perfection 
and safety with infrequent flights was trying to morale 
but was a demand which the Air group and associated 
ships' departments performed well. The Flight Sur- 
geons detected no pilot or air crew difficulties associated 
with the operation. 

Dental Summary 

In anticipation of increased dental work load, the 
department augmented supplies prior to departure from 
the Mediterranean. Enterprise facilities included six 
operatories with five Dental Officers assigned. 

The average work load during the prior deployment 
had been 2,200 procedures per month. During August 
the department performed 1,000 fillings, 200 extrac- 
tions, 2,586 preventive dental, endodontic and perio- 
dontic procedures and delivered 36 prosthetic appli- 
ances. September figures were comparable. This 
increased work load was attributable to the additional 
availability of patient personnel during the longer at- 
sea periods and slackened aviation operations. 

The two qualified oral surgeons aboard provided the 
coverage for maxillofacial surgery and backup for 
general anesthesia. 



18 



U.S. NAVY MEDICAL NEWS LETTER 



There were no serious dental emergencies and no 
problems other than increased material usage rates 
attributable to Operation Sea Orbit. 

Conclusions 

There were no medical, surgical, psychiatric, pre- 
ventive medical or dental factors which limited the 
readiness of Task Force One during Operation Sea 
Orbit. 

The incidence of all diseases and conditions was not 
significantly increased over the experience of normal 
deployments. 

Recommendations 

The Medical Officers of large Nuclear Task Forces 
planning more extended operating periods and isolation 
should : 

a. Anticipate greatly increased usage rates of some 
drugs and material. 

b. Consider careful medical and psychiatric screen- 
ing of personnel to strengthen Force morale and reduce 
psychogenic problem cases. 

AFTER THAT "HAIRY ONE" 

CDR John J. Gordon MC USN, Manned Spacecraft 
Center, National Aeronautics and Space Administra- 
tion, Houston, Texas. 

"Comes a pause in the day's operations!" This could 
present no better opportunity for the Flight Surgeon 
after a pilot has had an accident or has made one of 
those "beautiful saves" following a "hairy situation". 

There are few things outside of a forceps rotation 
during a transverse arrest in prolonged labor, or a 
strangulated bowel, which take precedence over the 
post-situational examination and interview of an aviator. 
He may be bathed in his own perspiration or the salty 
water of the mother sea. In either case, once any 
injury is diagnosed and satisfactorily treated, or in the 
case of no injury, it is vitally important that this avi- 
ator have a chance to talk. It may begin with his 
description of what happened or a mountain sized 
diatribe garnished with all the invectives of modern 
man. It behooves the Flight Surgeon to start this flow 
with either a few leading questions or an appropriate 
observation, and the subtility of the traditional two 
ounces of brandy. 

Once the aviator begins to talk do not interrupt other 
than to lead the narrative gently toward salient points. 
Stand by for a wealth of information and attitudes con- 
cerning himself, his job, the CAG, his skipper, the 
bull ensign (perhaps wingman), the LSO, wife, family, 
girl friend or even the old Doc himself. 



Our aviator may now find himself in the position of 
making an admission that he was or is afraid. Make 
it easy for him to express his fear but do not express 
it for him. Let him talk about it, mull it over and 
realize that fear can be a normal healthy emotion. At 
the same time, try to discover if his particular brand 
of fear is transient and produced by the situation or 
the more sinister kind which pervades him constantly, 
consciously or subconsciously. 

The attitude toward fear in most squadrons, par- 
ticularly among junior pilots, is the fear of fear. The 
more senior pilots have experienced the embrace of 
fear and readily admit it. This attitude being dissem- 
inated to junior pilots through casual discussion is very 
revealing and necessary to them. It is important that 
the aviator have an adequate understanding of fear. 
If in the months of association you think you know 
this aviator, you are now in a position to correct or 
augment your opinion. This is one fleeting moment 
when you may strengthen the bond of understanding 
and also let him convey his true feelings while allowing 
him the dignity of his calling as a man and aviator. 
In any case nothing shocks the interviewer. 

The Flight Surgeon's attitude during these interviews 
should be akin to the equanimity of Osier. Whether 
the situation requires five minutes or an hour, convey 
the impression that you have nothing more to do than 
to listen to him. At the same time there are leads 
trickling out of the conversation which may be perti- 
nent to the cause of the accident or the "save." These 
attitudes and impressions are important in evaluating 
the pilot's emotional equilibrium and his ability to 
perform under pressure. These are aptly described 
as the "Beef and Bones" of the flier's emotional mosaic. 

When this informal interview is concluded you 
should know whether the pilot is "up" or "down." In 
either case inform him so immediately and then pass* 
the word to the squadron skipper, preferably in person, 
and the ship's captain if at sea. Now you may set up 
further conversations if required or merely conduct the 
readyroom or wardroom coffee break observation as 
necessary. Never convey the idea that you have this 
pilot in a test tube for observation; it is entirely un- 
necessary. However, do not forget the advantage of a 
late evening visit to the pilot's stateroom where he is 
surrounded by nothing more than a stack of letters, his 
Hi-Fi and a picture of a beautiful woman. This is his 
world when not in the cockpit of his aircraft or in the 
readyroom and his attitudes here are very often naked 
and honest. 

Someone once denned naval aviation as "Prolonged 
periods of utter boredom interrupted by moments of 
stark terror." Here it is the calling of the Flight Sur- 
geon to shorten the sheer boredom and ease the in- 
tensity of the stark terror. 



U.S. NAVY MEDICAL NEWS LETTER 



MISCELLANY 

NURSING SEMINAR ON THE ACUTE CORONARY PATIENT 

CDR Martha O. Brandenburg NC USN, Chief of Nursing Service, Station Hospital, 
U.S. Naval Air Station, Patuxent River, Maryland. 



A Nursing Seminar on the Acute Coronary Patient 
in the Hospital sponsored by the Heart Association of 
Southern Maryland was hosted by the staff of the Sta- 
tion Hospital, Naval Air Station, Patuxent River, Mary- 
land, on 9 and 10 December 1964. Attendance was 
open to all medical, nursing, and allied medical per- 
sonnel interested and involved in whole patient care to 
include discharge planning. Approximately 125 persons 
attended each day. The patient was presented as seen 
by the doctor, hospital staff nurse, dietitian, public 
health nurse, vocation rehabilitationist, and the patient 
himself. The general theme of the seminar centered 
around the real need for the nurse to understand the 
experiences of her patient both physiologically and 
emotionally and determine accordingly her nursing 
activities since the nurse's attitude, manner, and re- 
sponse in making nursing judgments influence appre- 
ciably the subsequent recovery course of the patient. 

During the morning session a review of the physical 
changes and medical management of the patient was 
presented on 9 December by Dr. Robert T. Singleton, 
Assistant Professor of Medicine, University of Mary- 
land School of Medicine also Director, Cardiovascular 
Laboratory, University Hospital and on 10 December 
by Dr. Donald Dembo, Instructor in Medicine, Uni- 
versity of Maryland School of Medicine also Chief 
of Cardiology, Maryland General Hospital. Both Drs. 
Singleton and Dembo stressed the fact that coronary 
disease was not necessarily a disease of the aged but 
indeed a problem to all adults including in some cases 
noted changes in coronary arteries at the early age of 
twenty. Dr. Dembo stated that a concept is being 
developed and pushed to restore the patient who has 
suffered acute myocardial infarction to previous ac- 
tivity as quickly as possible inasmuch as those individ- 
uals so managed to do better than those who are placed 
on restricted activity. The role of the nurse was di- 
vided into two areas: (1) the emergency stage at the 
time of cardiac arrhythmia, i.e. cardiac arrest or sud- 
den death, (2) the healing process. 

In the hospital environment the nurse, nurses' aide 
or hospital corpsman is very often the first person to 
discover the patient experiencing cardiac arrhythmia. 
She must initiate immediate action in this sequence: 
(1) diagnose, (2) ventilate, (3) cardiac massage, 
(4) call for help. Many of the patients experiencing 
clinical death can be saved when immediate emergency 
measures are started within the first four to six min- 



utes prior to the onset of biological death. The im- 
mediate emergency need of the patient is ventilation 
by mouth to mouth or mouth to nose resuscitation 
methods. There is no advantage in stimulating heart- 
beat of a patient when there is no oxygenization of 
blood. Artificial respiration should be done rapidly 
for the first three to six times and repeated inter- 
mittently with fifteen seconds of heart stimulation using 
closed chest massage. A call must be made for help. 
Artificial ventilation must be continued until the pa- 
tient assumes spontaneously continuous respiration of 
adequate rate and depth. Upon arrival of the Medical 
Officer, the Nurse's role quickly changes to providing 
supportive care for the definitive cause of arrhythmia. 
Appropriate drugs are brought to the bedside, syringes 
filled, labeled, and refilled as necessary. All unneces- 
sary equipment and personnel should be removed from 
the patient environment and a defibrillator and an 
electrocardiograph brought to the bedside. Each move- 
ment of the nurse must be deliberate and effective 
since the demands of the moment leave no time for 
clumsiness or awkwardness. Many hospitals have 
organized emergency rescue teams that report on call 
to the area with appropriate mobile equipment and 
drugs; nevertheless, the nurse must be prepared to 
bridge the gap between the onset of the illness and the 
arrival of the emergency rescue team. 

Miss Lucille Kinlein RN, Director of the Cardio- 
vascular Disease Nursing Program at Catholic Uni- 
versity, gave a paper on Nursing Care of the Patient. 
She emphasized the importance of the nurse's role in 
her awareness and attitude toward the patient's fear of 
death. An atmosphere should be set in which the 
patient can feel free to express his anxieties. Actually, 
the long-time management begins with the onset. Many 
of the earlier reactions of the hospital staff to the pa- 
tient's pain, fear, and dyspnea will have a lasting effect 
on his response to his illness. Not only can the nurse 
keep the doctor informed of the needs, fears and 
problems of the patient, she can also assist the patient 
to cope with his problems through understanding, in- 
terpretation, and support. 

During the last hour of each day, a panel composed 
of the doctor, hospital nurse, public health nurse, 
dietitian, and vocational rehabilitationist discussed 
questions presented by the audience. 



20 



U.S. NAVY MEDICAL NEWS LETTER 



FOUR U.S. NAVY NURSE CORPS OFFICERS 

RECEIVE PURPLE HEART AWARDS 

IN VIETNAM 

ByJ.D. Tikaisky JOC USN 

SAIGON, January 8, 1965— Shortly before 6 P.M. 
on December 24, Ruth A. Mason entered the lobby of 
the Brink Bachelor Officers' Quarters here, where she 
paused to talk to her roommate, Frances L. Crumpton, 
who had just left Ann D. Reynolds in the suite which 
the three U.S. Navy nurses shared on the first floor. 

As they talked, an explosion caused by a Viet Cong 
Terrorist bomb rocked the building. The blast knocked 
Miss Crumpton to the floor, and flying debris struck 
Miss Mason and Miss Reynolds. A window frame blew 
in on another Navy nurse, Barbara J. Wooster, who 
was in her fourth-floor room. The blast ruptured both 
of Miss Crumpton's eardrums. Miss Mason received 
an injured back, and Miss Reynolds suffered a mild 
concussion. All were cut by flying glass. 

Moving from patient to patient in the courtyard in 
front of the hotel, the four, who are assigned with four 
other Navy nurses to the U.S. Navy Headquarters 
Support Activity, Saigon, Station Hospital, cleaned 
wounds and prepared the injured for evacuation to the 
hospital. 

When ambulances and other vehicles began arriving, 
the nurses left the scene of the blast and moved with 
the first loads of injured to the hospital, where they 
refused treatment for themselves and continued to care 
for those more seriously wounded. 

These four nurses became the first women members 
of the U.S. Armed Forces to receive the Purple Heart 
Award for injuries in the Viet Nam Conflict. 

During the awards ceremony, Headquarters Support 
Activity commanding officer CAPT Archie C. Kuntze 
USN, cited their actions as "beyond the call of duty" 
and "in keeping with the highest traditions of the Naval 
Service." 

"The fact that they were hurt themselves but work- 
ing on others had a tremendous morale effect on both 
the patients and the hospital staff," said CAPT R. A. 
Fisichella USN, senior medical officer. 

It was only after all the other 58 Americans and one 
Australian who had been injured were cared for that 
the nurses permitted doctors to treat their own wounds. 

Treating war wounded is an almost daily occurrence 
for nurses at the Navy hospital here, which is the only 
U.S. Navy medical facility in the world treating com- 
bat casualties direct from the field. A special plan to 
handle mass casualties is put into effect when large 
numbers of persons are wounded in incidents such as 
the Brink explosion. The Brink incident was one of 
three large explosions which have occurred in Saigon 
since the American effort was boosted in 1961. 



REPORT ON NEW U.S. NAVAL DENTAL 
TRAINING FILM 

Mr. Charles A. Greene, Film-TV Production Division, 
U.S. Naval Medical School, NNMC, Bethesda, Md. 
20014. 

A new dental training film, "Intraoral Roentgen- 
ography," (MN-9774), was released during last sum- 
mer and is now being distributed. The purpose of this 
23-minute color motion picture is to acquaint dental 
personnel with the advantages of variable-kilovoltage 
roentgenograph ic equipment and to demonstrate that 
the technique using parallel film placement and fixed 
exposure time with varying kilovoltages produces intra- 
oral roentgenograms of superior quality. 

An article in the 7 August issue of the News Letter 
(Vol. 44, No. 3, Dental Section) described in some 
detail the technique of parallel film placement and use 
of the extended tube or "long cone", and suggested 
KV settings for specific oral areas. The new training 
film will serve as a graphic demonstration of the prin- 
ciples stated. 

To establish a background against which to describe 
the use of improved equipment and techniques, the 
film first explains the principles of roentgen-ray gener- 
ation and shows some characteristics of the ray. It 
emphasizes control of radiation exposure by means 
of filtration, use of fast film and the increase of dis- 
tance. These sequences are in excellent animation that 
presents the principles so clearly that the statement 
will appeal to both the new learner and the experienced 
operator. 

A comparison of the angle-bisection technique with 
that employing parallel placement of the roentgeno- 
graph^ film is also presented in animation. Live-action 
sequences follow, showing precisely how the parallel- 
placement technique works in various areas of the 
mouth, in combination with right-angle positioning of 
the "long cone". The film explains the use of increased 
kilovoltage for optimum penetration, control of radia- 
tion exposure and improvement of image quality. 
Roentgenographic films of actual cases are of course 
included to show the results of the improved techniques 
described, as compared with results of those formerly 
used. 

Prints of "Intraoral Roentgenography" are being 
distributed to all naval hospitals in the United States 
and to certain specialized facilities for training of 
dental personnel. 

ADDENDUM TO ARTICLE ON USNH, 

PHILADELPHIA, DESCRIBING THE U.S. 

NAVAL AURAL REHABILITATION CENTER 

The article in the November 27th issue of Medical 
News Letter concerning the U.S. Naval Aural Re- 



U.S. NAVY MEDICAL NEWS LETTER 



21 



habilitation Center was prepared by Mr. Joseph Scan- 
Ion, Director of the Aural Rehabilitation Center, under 
the supervision of Commander G. R. Hart, Chief of 
Department of Otolaryngology. Further reference 
material regarding the work of this Center may be 



found in the following sources: 1. "The Rehabilitation 
Program of the Navy: Aural Casualties", Laryngo- 
scope page 489, Sept 1944. 2. "Rehabilitations of 
Hearing and Speech." U.S. Naval Medical Bulletin, 
March 1946."— Editor 



SPECIAL ARTICLES 



CAT SCRATCH DISEASE 

A Report on the Experiences of CAPT A. M. Margileth, 
Chief of Pediatric Service, USNH, Bethesda, Md. 

NEW YORK — Skin test antigen has proven to be a 
useful differential diagnostic tool in cat scratch dis- 
ease. According to CAPT A. M. Margileth of a U.S. 
Navy Pediatric Service, the antigen can be used with, 
at the very least, "95% confidence." 

In a report to the annual meeting of the American 
Academy of Pediatrics, the naval pediatrician detailed 
his experience with 41 young patients (most under 20 
years of age) over the past seven years. 

When the skin test antigen was used in the 41 cases 
studied at the U.S. Naval Hospitals in Chelsea, Mass., 
and Bethesda, Md., all patients had a positive reaction 
which correlated well with the clinical diagnosis. Other 
studies have shown only 3% to 4% positive reactions 
in control (well child) groups. No false positive skin 
tests were observed in over 60 patients with tubercu- 
losis, infectious mononucleosis, tularemia, brucellosis 
and Hodgkin's disease and bacterial lymphadenitis. 

It was noted that while lymphogranuloma venereum, 
syphilis and toxoplasmosis are rarely encountered in 
young children, they should also be considered when 
marking a differential diagnosis. 

Most of the cat scratch disease patients exhibited 
the usual features — a primary lesion followed by fever, 
malaise and subacute regional adenitis, with gradual 
resolution in one to two months. Several of the 
Bethesda pediatrician's cases had unusual manifesta- 
tions, for example, atypical pneumonia, encephalitis, 
popliteal space tumor or the oculoglandular form of 
the disease. 

CAPT Margileth also confirmed the findings of 
others that the disease occurs more frequently during 
the fall and winter months and that it infects children 
and teenagers much more often than adults. "It is 
usually transmitted by a scratch or lick of a cat, but 
in rare instances, dogs have been implicated," he said. 
"The disease is not transmitted from man to man, so 
neither isolation nor quarantine is indicated." 

The Bethesda pediatrician noted that his repeated 
attempts to isolate the causative agent were unsuccess- 
ful, as they have been in other studies, though it is 
presumed to be a virus. 



"Management of the patients was directed first 
toward the primary lesion if present," CAPT Margileth 
said. "Moist compresses which promoted drainage 
appeared to shorten the duration of the regional lym- 
phadenopathy." 

In some of the cases, the naval pediatrician per- 
formed excisional biopsy of the primary lesion or a 
regional bubo. He found that if suppuration of the 
bubo occurred, repeated aspiration using local anes- 
thesia was the most effective and least traumatic 
therapy. 

"Closed aspiration is simple, can be performed 
quickly in the office, and provides material for culture 
and preparation for more antigen," he explained. 
"Antibiotics are ineffective and were used only for 
secondary bacterial complications, which were rarely 
encountered." 

CAPT Margileth noted that the prognosis was ex- 
cellent for all of his patients. There were no sequelae, 
and second attacks did not occur. 

PEDIATRIC OFFICE BACTERIOLOGY* 

CAPT Andrew M. Margileth MC USN, Chief of 

Pediatric Service, U.S. Naval Hospital, NNMC, 

Bethesda, Md. 

Streptococcal infections have been largely controlled 
with proper recognition and therapy. The serious and 
long lasting sequelae that were formerly seen are 
relatively rare. It must be granted that all infections 
cannot be cured even when properly treated by present 
methods, but results will only be good in those cases 
that are amenable to therapy when the disease proc- 
esses are properly recognized. This recognition of in- 
fection is not, however, as simple as generally believed. 
Many clinicians state that it is easy to recognize 
streptococcal pharyngitis, but this is not always true. 
Improper diagnoses have been reported 25 to 65 per 
cent of the time and then generally too much, too 
little, or inappropriate therapy has been instituted. 

Our answer to this confusion is the utilization of 
culture facilities in the pediatric outpatient clinic. 
Rather than send the patient to a laboratory, we take 
the cultures, incubate them for 18 to 24 hours, and 

* Adapted, in part, from Proceedings of the Monthly Staff Confer- 
ences, USNH, Bethesda, Maryland, 15 Nov 1963; also. Guest Edi- 
torial, Medical Tribune. 



22 



U.S. NAVY MEDICAL NEWS LETTER 



then read them. In doubtful situations we check for 
beta hemolysis with a microscope and do gram stains. 
This is an office aid to diagnosis which is relatively 
inexpensive, and simple to perform in a clinical prac- 
tice of 100 patients each day. 

Some of our colleagues practicing medicine will 
admit that diagnosis of what is and what is not strep- 
tococcal infection is sometimes difficult, but they object 
to the routine use of cultures for the following reasons: 
(1) Delay in reporting: the average clinical laboratory 
will return results in 3 to 5 days, a time lag which is 
difficult to overcome. We have our report in 24 to 48 
hours. (2) Cost: the high cost of culture plates, 
media and throat swabs ($5 to $15). Our costs have 
averaged $1.00 per patient. (3) Time: many physi- 
cians feel that they cannot take time to explain to the 
patient or the family the necessity for a culture when 
an antibiotic will probably be given anyway. (4) Cum- 
bersome: many physicians state that fluorescent anti- 
body techniques will be available in the near future 
and then therapy can be instituted quickly and ac- 
curately as indicated. Although it is true that these 
techniques are just as accurate and results are available 
sooner, they must be performed in a standard labora- 
tory, and such facilities generally are not available to 
the clinician. 

These objections are valid; however, they can be 
overcome with the use of a small incubator in the 



office, and commercially prepared blood plates, and a 
few minutes to read the plates each morning. The 
patients' case histories can be reviewed as each plate 
is examined. In this way, the delay of the report and 
the time factor can be minimized. Cost is also reduced 
for the patient. The initial financial outlay for the 
necessary equipment is reasonable and in terms of 
patient interest and appreciation (not to mention the 
cost of 5 to 10 days of antibiotic treatment which may 
be unnecessary) the original investment will be quickly 
returned. 

In spite of a busy schedule with large numbers of 
patients, we have had a rewarding experience with 
culture facilities in our clinic. We have a large group 
of physicians in training who come from many disci- 
plines and teaching experiences. All of us gain knowl- 
edge with the correlation of the clinical and bacterio- 
logic diagnoses. This, we feel, is medical education; 
but also is a type of education that carries' over to 
the parent. We have found it easy to convince people 
that it is important to delay therapy in order to develop 
antibody response. The opportunity to determine ap- 
propriate antibiotic therapy in those patients that do 
have a specific bacterial infection is most valuable. In 
the long run, we are able to save extra cost to the 
patients that are not overtreated with antibiotics. It is 
not an unusual situation now, to have parents ask for 
a culture instead of an antibiotic. 



Ever since the Second World War the need has been felt for a code of ethics concerning experiments carried out 
on human beings in the name of medicine. After an intensive examination of the subject extending over several 
years, such a code has now been adopted by the World Medical Association. — WHO Chronicle 19(1): 31, 
January 1965. 



The legal measures on radiation protection introduced in a number of countries in recent years have tended to 
concentrate on the hazards arising from the various uses of nuclear energy. Yet x-rays — which are often not even 
mentioned in the legislation — at present constitute by far the greatest msn-made source of radiation exposure. 
—WHO Chronicle 19(1): 34, January 1965. 



"Much of our citizenry takes seapower for granted, never surprised when Navy ships turn up in various hot- 
spots around the world. I hope our Naval presence will always be available, but I emphasize that seapower is so 
important to our nation that it must never be neglected or underestimated. There is an immense penalty attached 
to failure to understand the use of the sea and the need to control it." 

Admiral David L, McDonald 
Baltimore Sun 



It is becoming increasingly clear that the control of gonorrhoea is unlikely to be achieved except by mass treat- 
ment or by some type of immunoprophylaxis. The recent development of trial vaccines against cerebrospinal 
meningitis may help to advance research on the immunology of gonorrhoea, since the agents of both diseases 
belong on the Neisseriae group and are crossreactive serologically. — WHO Chronicle 19(1): 9, January 1965. 



U.S. NAVY MEDICAL NEWS LETTER 



23 



ANTICANCER RESEARCH 



ELECTRIC "BARRIERS" FOR SNAIL CONTROL 



The National Cancer Institute, Public Health Service, 
and the National Aeronautics and Space Administration 
are cooperating in a 1-year medical research project to 
study the anticancer, carcinogenic, and antiradiation 
potentials of a group of chemicals closely related to 
plant growth regulators. 

The study extends earlier NASA research that 
showed that certain plant growth regulators which pro- 
long the life of cancer cells in a test tube can produce 
a lethal effect when altered. Mixtures of the regulators 
and their related compounds were even more lethal. 

The effects of a variety of these compounds on tumor 
cells in test tubes and in laboratory animals and on 
the survival of irradiated normal and tumor-bearing 
mice are being investigated. 

The research is being conducted in the Space and 
Information Systems Division of North American 
Aviation, Downey, Calif., under a $198,185 contract 
with the Public Health Service. The National Cancer 
Institute is providing technical direction for the project, 
which is being financed through a transfer of funds to 
the Public Health Service by NASA under its tech- 
nology utilization program. — Public Health Reports 
79(12): 1080, December 1964. 



Further investigations into an electrical "barrier" 
system, which might be useful in the control of aquatic 
snails are recommended in the fourteenth report of 
the WHO Expert Committee on Insecticides. 

It has been observed that when an electric current is 
passed through water where aquatic snails are sub- 
merged, they move rapidly towards one of the elec- 
trodes. This phenomenon, it is felt, might be put to 
good account as a control measure against bilharziasis 
by preventing, for example, the migration of snails 
past given points in a stream system. 

The Committee also draws attention to the possibility 
of applying molluscicides to rivers and ponds by placing 
the chemical in a porous-walled container, from which 
it would slowly escape by diffusion. This is similar in 
principle to the old method of suspending burlap bags 
of copper sulfate in the flow, but the use of a porous- 
walled container might permit a more constant flow 
of molluscicide as particle size would no longer play 
a part. The attraction of the method lies in its extreme 
simplicity and in the fact that the containers can be 
left completely submerged, thus minimizing the chance 
of their being tampered with while unattended. — WHO 
Chronicle 18(11): 431, November 1964. 



Some drugs appear to have a prophylactic action against smallpox and may prove to be of considerable help in 
the control of the disease. But their action is short-lived, so that the population in endemic areas would still have 
to be vaccinated and revaccinated periodically. — WHO Chronicle 18(11); November 1964. 



DEPARTMENT OF THE NAVY 

U. S. NAVAL MEDICAL SCHOOL 

NATIONAL NAVAL MEDICAL CENTER 

BETHESDA. MARYLAND 20014 

OFFICAL BUSINESS 

PERMIT NO. 1048 



POSTAGE AND FEES PAID 
NAVY DEPARTMENT 



24 



U.S. NAVY MEDICAL NEWS LETTER